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Rieu R, Prestwich RJ, Paterson C, Vohra S, Swan A, Noble D, Srinivasan D, Dixon L, Chiu K, Scott A, Mendes R, Khan S, Pilar A, Thompson A, Nutting CM, McPartlin A. A Multicenter Study of Clinician and Patient Reported Acute and Late Toxicity after Radical (Chemo)Radiotherapy for Non-Endemic Nasopharyngeal Cancer. Int J Radiat Oncol Biol Phys 2023; 117:e619. [PMID: 37785855 DOI: 10.1016/j.ijrobp.2023.06.2001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Curative (chemo)radiotherapy ((CT)RT) for Nasopharyngeal cancers (NPC) achieves excellent disease control but is associated with significant late toxicities despite modern treatment delivery. Contemporary late toxicity data, including patient reported outcomes (PROs), is limited in the non-endemic population; we present a large contemporary series of toxicity outcomes and late PROs following treatment of non-endemic NPC. MATERIALS/METHODS Adult patients completing radical (CT)RT for primary NPC between February 2016 and 2020 at 7 large UK cancer centers were identified on institutional databases. Patients were excluded if they had prior head and neck cancer or prior therapeutic head and neck surgery (except neck dissection). Patients with an active other cancer were excluded from PRO assessment. Demographic, treatment, acute toxicity and outcome data were collected retrospectively from patient records. Disease-free patients were invited to complete an M.D. Anderson Dysphagia Index (MDADI) and University of Washington (UoW) Quality of Life (QoL) PROs questionnaires. RESULTS A total of 180 eligible patients were identified: 68% male, median age 54 years, 11% ≥70 years. EBV status was positive in 61% (unknown 12%). Patients had stage I (5%), II (22%), III (37%), IV (36%) disease; 95% were performance status ≤1 at baseline. Median follow-up was 31.2 months (range 0-68). A total of 54% received 70Gy in 33-35# and 43% received 65-66 Gy in 30-33#. 66% received induction and 65% received concurrent chemotherapy. 9.5% had residual disease at the first follow-up scan. Subsequent locoregional or distant recurrence occurred in 5% and 12% respectively. At last assessment, 84% patients were alive, 16% had died (of which 70% had active disease). Acute treatment toxicity included: 63% of patients required enteral support (median duration 98 days) with 9% a feeding tube at 1 year post treatment. 18% G3 dermatitis, 53% G3 mucositis. 82% requiring opioids and 40% admitted for symptom management. 90 patients completed the PROs (76% response rate) at a median of 37.8 months post treatment (Table 1). These demonstrate significant QoL detriment: 28% report significant pain, 24% require regular analgesia, and 59% report significant impact on daily activity. This was found to persist at different timepoints (not shown). CONCLUSION Excellent cancer survival outcomes are seen in a non-selected, non-endemic NPC population. However significant acute and late toxicity following radical treatment is identified which can profoundly negatively impact QoL in a relatively young cohort. This highlights the importance of ongoing efforts to reduce toxicity and supports the prospective evaluation of potential toxicity sparing technologies, such as proton beam radiotherapy.
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Affiliation(s)
- R Rieu
- The Royal Marsden Hospital NHS Foundation Trust, London, United Kingdom
| | - R J Prestwich
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - C Paterson
- Beatson West of Scotland Cancer Centre, Radiation Oncology Department, Glasgow, United Kingdom
| | - S Vohra
- Beaton West of Scotland Cancer Centre, Glasgow, United Kingdom
| | - A Swan
- Edinburgh Cancer Centre, Western General Hospital, Crewe Road South, Edinburgh, United Kingdom
| | - D Noble
- Edinburgh Cancer Centre, Western General Hospital, Crewe Road South, Edinburgh, United Kingdom
| | - D Srinivasan
- Western General Hospital, Edinburgh, United Kingdom
| | - L Dixon
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK, Sheffield, United Kingdom
| | - K Chiu
- Mount Vernon Cancer Centre, Department of Clinical Oncology, Northwood, United Kingdom
| | - A Scott
- Mount Vernon Hospital, Department of Clinical Oncology, Northwood, United Kingdom
| | - R Mendes
- University College London Hospital, London, United Kingdom
| | - S Khan
- University College London Hospital, London, United Kingdom
| | - A Pilar
- University College London Hospital, London, United Kingdom
| | - A Thompson
- North Middlesex University Hospital, Cambridge CB2 8AP, United Kingdom
| | - C M Nutting
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - A McPartlin
- Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada
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Cardenas CE, Blinde SE, Mohamed ASR, Ng SP, Raaijmakers C, Philippens M, Kotte A, Al-Mamgani AA, Karam I, Thomson DJ, Robbins J, Newbold K, Fuller CD, Terhaard C, On Behalf Of The, Bahig H, Blanchard P, Dehnad H, Doornaert P, Elhalawani H, Frank SJ, Garden A, Gunn GB, Hamming-Vrieze O, Kamal M, Kasperts N, Lee LW, McDonald BA, McPartlin A, Meheissen MA, Morrison WH, Navran A, Nutting CM, Pameijer F, Phan J, Poon I, Rosenthal DI, Smid EJ, Sykes AJ. Comprehensive Quantitative Evaluation of Variability in MR-guided Delineation of Oropharyngeal Gross Tumor Volumes and High-risk Clinical Target Volumes: An R-IDEAL Stage 0 Prospective Study. Int J Radiat Oncol Biol Phys 2022; 113:426-436. [PMID: 35124134 DOI: 10.1016/j.ijrobp.2022.01.050] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 01/12/2022] [Accepted: 01/26/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE Tumor and target volume manual delineation remains a challenging task in head-and-neck cancer radiotherapy. The purpose of this study was to conduct a multi-institutional evaluation of manual delineations of gross tumor volume (GTV), high-risk clinical target volume (CTV), parotids, and submandibular glands on treatment simulation MR scans of oropharyngeal cancer (OPC) patients. METHODS Pre-treatment T1-weighted (T1w), T1-weighted with gadolinium contrast (T1w+C) and T2-weighted (T2w) MRI scans were retrospectively collected for 4 OPC patients under an IRB-approved protocol. The scans were provided to twenty-six radiation oncologists from seven international cancer centers who participated in this delineation study. In addition, patients' clinical history and physical examination findings, along with a medical photographic image and radiological results, were provided. The contours were compared using overlap/distance metrics using both STAPLE and pair-wise comparisons. Lastly, participants completed a brief questionnaire to assess participants' experience and CTV delineation institutional practices. RESULTS Large variability was measured between observers' delineations for GTVs and CTVs. The mean Dice Similarity Coefficient values across all physicians' delineations for GTVp, GTVn, CTVp, and CTVn were 0.77, 0.67, 0.77, and 0.69, respectively, for STAPLE comparison and 0.67, 0.60, 0.67, and 0.58, respectively, for pair-wise analysis. Normal tissue contours were defined more consistently when considering overlap/distance metrics. The median radiation oncology clinical experience was 7 years. The median experience delineating on MRI was 3.5 years. The GTV-to-CTV margin used was 10 mm for six of seven participant institutions. One institution used 8 mm and three participants (from three different institutions) used a margin of 5 mm. CONCLUSION The data from this study suggests that appropriate guidelines, contouring quality assurance sessions, and training are still needed for the adoption of MR-based treatment planning for head-and-neck cancers. Such efforts should play a critical role in reducing delineation variation and ensure standardization of target design across clinical practices.
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Affiliation(s)
- Carlos E Cardenas
- Department of Radiation Oncology, The University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Sanne E Blinde
- Department of Radiation Oncology, Klinikum Kassel, Kassel, Germany
| | - Abdallah S R Mohamed
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sweet Ping Ng
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Department of Radiation Oncology, Olivia Newton-John Cancer Centre, Austin Health, Melbourne, Australia
| | - Cornelis Raaijmakers
- Department of Radiotherapy, Division of Imaging & Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marielle Philippens
- Department of Radiotherapy, Division of Imaging & Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Alexis Kotte
- Department of Radiotherapy, Division of Imaging & Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Abrahim A Al-Mamgani
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Irene Karam
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Science Centre, University of Toronto, Toronto, ON, Canada
| | - David J Thomson
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Jared Robbins
- Department of Radiation Oncology, University of Arizona, Tucson, Arizona, USA
| | - Kate Newbold
- Royal Marsden NHS Foundation Trust and Institute of Cancer Research, London, UK
| | - Clifton D Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
| | - Chris Terhaard
- Department of Radiotherapy, Division of Imaging & Oncology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - On Behalf Of The
- Department of Radiation Oncology, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Houda Bahig
- Department of Radiation Oncology, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Pierre Blanchard
- Department of Radiation Oncology, Institut Gustave Roussy, Villejuif, France
| | - Homan Dehnad
- Department of Radiotherapy, Division of Imaging & Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Patricia Doornaert
- Department of Radiotherapy, Division of Imaging & Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hesham Elhalawani
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Adam Garden
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - G Brandon Gunn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Olga Hamming-Vrieze
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Mona Kamal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nicolien Kasperts
- Department of Radiotherapy, Division of Imaging & Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lip Wai Lee
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Brigid A McDonald
- Department of Radiation Oncology, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Andrew McPartlin
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Mohamed Am Meheissen
- Alexandria Clinical Oncology Department, Alexandria University, Alexandria, Egypt
| | - William H Morrison
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Arash Navran
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Frank Pameijer
- Department of Radiology, Division of Imaging & Oncology, University Medical Center, Utrecht, The Netherlands
| | - Jack Phan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ian Poon
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Science Centre, University of Toronto, Toronto, ON, Canada
| | - David I Rosenthal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ernst J Smid
- Department of Radiotherapy, Division of Imaging & Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Andrew J Sykes
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK
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Nutting CM, Griffin CL, Sanghera P, Foran B, Beasley M, Bernstein D, Cosgrove V, Fisher S, West CM, Sibtain A, Palaniappan N, Urbano TG, Sen M, Soe W, Rizwanullah M, Wood K, Ramkumar S, Junor E, Cook A, Roques T, Scrase C, Bhide SA, Gujral D, Harrington KJ, Mehanna H, Miah A, Emson M, Gardiner D, Morden JP, Hall E. Dose-escalated intensity-modulated radiotherapy in patients with locally advanced laryngeal and hypopharyngeal cancers: ART DECO, a phase III randomised controlled trial. Eur J Cancer 2021; 153:242-256. [PMID: 34256319 DOI: 10.1016/j.ejca.2021.05.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 03/30/2021] [Accepted: 05/09/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Radical (chemo)radiotherapy offers potentially curative treatment for patients with locally advanced laryngeal or hypopharyngeal cancer. We aimed to show that dose-escalated intensity-modulated radiotherapy (DE-IMRT) improved locoregional control. METHODS We performed a phase III open-label randomised controlled trial in patients with laryngeal or hypopharyngeal cancer (AJCC III-IVa/b, TNM 7). Patients were randomised (1:1) to DE-IMRT or standard dose IMRT (ST-IMRT) using a minimisation algorithm, balancing for centre, tumour site, nodal status and chemotherapy use. DE-IMRT was 67.2 gray (Gy) in 28 fractions (f) to the primary tumour and 56Gy/28f to at-risk nodes; ST-IMRT was 65Gy/30f to primary tumour and 54Gy/30f to at-risk nodes. Suitable patients received 2 cycles of concomitant cisplatin and up to 3 cycles of platinum-based induction chemotherapy. The primary end-point was time to locoregional failure analysed by intention-to-treat analysis using competing risk methodology. FINDINGS Between February 2011 and October 2015, 276 patients (138 ST-IMRT; 138 DE-IMRT) were randomised. A preplanned interim futility analysis met the criterion for early closure. After a median follow-up of 47.9 months (interquartile range 37.5-60.5), there were locoregional failures in 38 of 138 (27.5%) ST-IMRT patients and 42 of 138 (30.4%) DE-IMRT patients; an adjusted subhazard ratio of 1.16 (95% confidence interval: 0.74-1.83, p = 0.519) indicated no evidence of benefit with DE-IMRT. Acute grade 2 pharyngeal mucositis was reported more frequently with DE-IMRT than with ST-IMRT (42% vs. 32%). No differences in grade ≥3 acute or late toxicity rates were seen. CONCLUSION DE-IMRT did not improve locoregional control in patients with laryngeal or hypopharyngeal cancer. The trial is registered: ISRCTN01483375.
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Affiliation(s)
| | | | | | | | | | - David Bernstein
- Department of Physics, The Royal Marsden Hospital, London, UK
| | | | | | | | | | | | | | | | | | | | - Katie Wood
- Royal Surrey County Hospital, Guildford, UK
| | | | | | | | - Tom Roques
- Norfolk and Norwich University Hospital, UK
| | | | | | | | | | - Hisham Mehanna
- The Institute for Head and Neck Studies and Education, University of Birmingham, Birmingham, UK
| | | | - Marie Emson
- The Institute of Cancer Research, London, UK
| | | | | | - Emma Hall
- The Institute of Cancer Research, London, UK
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McCaul JA, Nankivell PC, Nutting CM. Invited commentary on "Initial surgical versus non-surgical treatments for advanced hypopharyngeal cancer; a meta-analysis with trial sequential analysis" (Int J Surg 2020; Epub ahead of print). Int J Surg 2020; 81:107-108. [PMID: 32682977 DOI: 10.1016/j.ijsu.2020.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 07/06/2020] [Indexed: 11/24/2022]
Affiliation(s)
- James A McCaul
- Regional Maxillofacial Unit, Queen Elizabeth University Hospital Campus, 1345 Govan Road, Glasgow, G51 4TF, UK; The Institute for Cancer Therapeutics, University of Bradford, UK.
| | - Paul C Nankivell
- Institute of Head and Neck Studies, Institute of Cancer and Genomic Sciences, University of Birmingham, B15 2TT, UK; University Hospital Birmingham, UK
| | - Christopher M Nutting
- The Royal Marsden and the Institute for Cancer Research, Fulham Road, Chelsea, London, SW3 6JJ, UK
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5
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Nenclares P, Bhide SA, Sandoval-Insausti H, Pialat P, Gunn L, Melcher A, Newbold K, Nutting CM, Harrington KJ. Impact of antibiotic use during curative treatment of locally advanced head and neck cancers with chemotherapy and radiotherapy. Eur J Cancer 2020; 131:9-15. [PMID: 32248073 DOI: 10.1016/j.ejca.2020.02.047] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 02/15/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Pre-clinical evidence suggests reduced efficacy of anticancer treatment in patients exposed to broad-spectrum antibiotics. It is hypothesised that this phenomenon may be explained by the effects of antibiotics on the composition of the microbiota. To assess this in a clinical setting, we analysed the impact of antibiotics in patients with locally advanced head and neck cancer (LAHNC) treated with curative intent with chemotherapy and radiotherapy (RT). MATERIAL AND METHODS Retrospective data for LAHNC patients treated with curative intent (245 induction chemotherapy followed by chemoradiation [CRT], 17 surgery followed by post-operative CRT, six CRT, three RT alone and one RT with concurrent cetuximab) were analysed. We evaluated the impact of antibiotics prescribed during primary anti-cancer treatment on progression-free survival (PFS), overall survival (OS) and disease-specific survival (DSS) rates by multivariate Kaplan-Meier and Cox proportional hazards regression analysis. RESULTS Among 272 patients, those receiving antibiotics between within 1 week before and 2 weeks after treatment (N = 124) progressed significantly earlier and had lower OS and DSS rates. In the multivariate analysis, administration of antibiotics was independently associated with reduced PFS (hazards ratio [HR] 1.98, P = 0.001), OS (HR 1.85, P = 0.001) and DSS (HR 1.95, P = 0.004). This effect was maintained with independence of reason for prescription, type and time of antibiotic prescription. The negative impact was greater for patients who received two or more courses of antibiotics. Antibiotic treatment was correlated with increased risk of locoregional relapse. CONCLUSIONS Our data suggest a negative impact of antibiotic therapy on treatment outcomes following CRT with curative intent in patients with LAHNC. This potential harm should be considered when prescribing broad-spectrum and prophylactic antibiotics for such patients.
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Affiliation(s)
- Pablo Nenclares
- Head and Neck Unit, Royal Marsden Hospital, London, United Kingdom.
| | - Sheerang A Bhide
- Head and Neck Unit, Royal Marsden Hospital, London, United Kingdom; Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom
| | | | - Pierre Pialat
- Radiation Oncology Department, Centre Léon Bérard, Lyon, France
| | - Lucinda Gunn
- Head and Neck Unit, Royal Marsden Hospital, London, United Kingdom; Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom
| | - Alan Melcher
- Head and Neck Unit, Royal Marsden Hospital, London, United Kingdom; Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom
| | - Kate Newbold
- Head and Neck Unit, Royal Marsden Hospital, London, United Kingdom; Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom
| | - Christopher M Nutting
- Head and Neck Unit, Royal Marsden Hospital, London, United Kingdom; Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom
| | - Kevin J Harrington
- Head and Neck Unit, Royal Marsden Hospital, London, United Kingdom; Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom
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Chatterjee S, Ghosh Laskar S, Mehanna H, Nutting CM, Mallick I. Oropharyngeal Cancers in the East and the West - Implications of Aetiopathogenesis on Prognosis and Research. Clin Oncol (R Coll Radiol) 2019; 31:510-519. [PMID: 31196762 DOI: 10.1016/j.clon.2019.05.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 04/30/2019] [Accepted: 05/09/2019] [Indexed: 10/26/2022]
Abstract
There has been a surge in human papillomavirus (HPV)-positive oropharyngeal cancers (OPCs) in the West. Although the prognosis of HPV-positive OPC is good, de-escalation strategies have so far not been able to confirm comparable cancer control. We examine the strategies implemented across the globe to safely reduce toxicities in HPV-positive disease. HPV-negative OPC has a poorer prognosis and is more prevalent in Eastern countries. We outline the intensification strategies currently used in HPV-negative cancers, with an aim to better prognosis. With recent improvements in clinical trial frameworks in Eastern countries such as India, we discuss areas where joint collaborative research between Western and Eastern countries could further improve outcomes in OPC.
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Affiliation(s)
- S Chatterjee
- Department of Radiation Oncology, Tata Medical Center, Kolkata, India.
| | - S Ghosh Laskar
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, India
| | - H Mehanna
- Institute of Head and Neck Studies and Education, Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - C M Nutting
- Department of Clinical Oncology, Royal Marsden Hospital and Institute of Cancer Research, London, UK
| | - I Mallick
- Department of Radiation Oncology, Tata Medical Center, Kolkata, India
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7
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Gujral DM, Nutting CM. Patterns of failure, treatment outcomes and late toxicities of head and neck cancer in the current era of IMRT. Oral Oncol 2018; 86:225-233. [DOI: 10.1016/j.oraloncology.2018.09.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 09/08/2018] [Accepted: 09/11/2018] [Indexed: 10/28/2022]
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8
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Nutting CM, Morden JP, Beasley M, Bhide S, Cook A, De Winton E, Emson M, Evans M, Fresco L, Gollins S, Gujral D, Harrington K, Joseph M, Lemon C, Luxon L, van den Blink Q, Mendes R, Miah A, Newbold K, Prestwich R, Robinson M, Sanghera P, Simpson J, Sivaramalingam M, Srihari NN, Sydenham M, Wells E, Witts S, Hall E. Results of a multicentre randomised controlled trial of cochlear-sparing intensity-modulated radiotherapy versus conventional radiotherapy in patients with parotid cancer (COSTAR; CRUK/08/004). Eur J Cancer 2018; 103:249-258. [PMID: 30286418 PMCID: PMC6202674 DOI: 10.1016/j.ejca.2018.08.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 08/01/2018] [Accepted: 08/02/2018] [Indexed: 12/25/2022]
Abstract
Purpose About 40–60% of patients treated with post-operative radiotherapy for parotid cancer experience ipsilateral sensorineural hearing loss. Intensity-modulated radiotherapy (IMRT) can reduce radiation dose to the cochlea. COSTAR, a phase III trial, investigated the role of cochlear-sparing IMRT (CS-IMRT) in reducing hearing loss. Methods Patients (pT1-4 N0-3 M0) were randomly assigned (1:1) to 3-dimensional conformal radiotherapy (3DCRT) or CS-IMRT by minimisation, balancing for centre and radiation dose of 60Gy or 65Gy in 30 daily fractions. The primary end-point was proportion of patients with sensorineural hearing loss in the ipsilateral cochlea of ≥10 dB bone conduction at 4000 Hz 12 months after radiotherapy compared using Fisher's exact test. Secondary end-points included hearing loss at 6 and 24 months, balance assessment, acute and late toxicity, patient-reported quality of life, time to recurrence and survival. Results From Aug 2008 to Feb 2013, 110 patients (54 3DCRT; 56 CS-IMRT) were enrolled from 22 UK centres. Median doses to the ipsilateral cochlea were 3DCRT: 56.2Gy and CS-IMRT: 35.7Gy (p < 0.0001). 67/110 (61%) patients were evaluable for the primary end-point; main reasons for non-evaluability were non-attendance at follow-up or incomplete audiology assessment. At 12 months, 14/36 (39%) 3DCRT and 11/31 (36%) CS-IMRT patients had ≥10 dB loss (p = 0.81). No statistically significant differences were observed in hearing loss at 6 or 24 months or in other secondary end-points including patient-reported hearing outcomes. Conclusion CS-IMRT reduced the radiation dose below the accepted tolerance of the cochlea, but this did not lead to a reduction in the proportion of patients with clinically relevant hearing loss. Ipsilateral hearing loss is experienced by 35–40% of patients having radiotherapy to their parotid. Reducing the radiation dose to the cochlea does not spare hearing loss. The radiosensitivity of the cochlea may be much greater than previously understood.
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Affiliation(s)
| | - James P Morden
- The Institute of Cancer Research Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Matthew Beasley
- Bristol Cancer Institute, Bristol Haematology and Oncology Centre, United Kingdom
| | - Shreerang Bhide
- Head and Neck Unit, Royal Marsden Hospital, London, United Kingdom
| | - Audrey Cook
- Gloucestershire Oncology Centre, Cheltenham General Hospital, United Kingdom
| | - Emma De Winton
- Department of Oncology, Royal United Hospital, Bath, United Kingdom
| | - Marie Emson
- The Institute of Cancer Research Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Mererid Evans
- Clinical Oncology, Velindre NHS Trust, United Kingdom
| | - Lydia Fresco
- Department of Oncology, University Hospitals of Coventry and Warwickshire, United Kingdom
| | - Simon Gollins
- Department of Oncology, Glan Clwyd Hospital, Rhyl, United Kingdom
| | - Dorothy Gujral
- Head and Neck Department, Imperial College Healthcare NHS Trust, United Kingdom; Sarcoma Unit, Royal Marsden Hospital, Sutton, United Kingdom
| | - Kevin Harrington
- Head and Neck Unit, Royal Marsden Hospital, London, United Kingdom
| | - Mano Joseph
- Oncology and Haematology Directorate, The Royal Wolverhampton NHS Trust, United Kingdom
| | - Catherine Lemon
- Department of Oncology, Mount Vernon Hospital, United Kingdom
| | - Linda Luxon
- University College London Ear Institute, United Kingdom
| | | | - Ruheena Mendes
- Department of Oncology, University College Hospital, London, United Kingdom
| | - Aisha Miah
- Head and Neck Department, Imperial College Healthcare NHS Trust, United Kingdom; Sarcoma Unit, Royal Marsden Hospital, Sutton, United Kingdom
| | - Kate Newbold
- Head and Neck Unit, Royal Marsden Hospital, London, United Kingdom
| | - Robin Prestwich
- Department of Clinical Oncology, St James's University Hospital, Leeds, United Kingdom
| | - Martin Robinson
- Department of Clinical Oncology, Weston Park Hospital, Sheffield, United Kingdom
| | - Paul Sanghera
- Department of Oncology, University Hospitals Birmingham NHS Foundation Trust, United Kingdom
| | - Joanna Simpson
- Department of Oncology, Royal Sussex County Hospital, United Kingdom
| | | | | | - Mark Sydenham
- The Institute of Cancer Research Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Emma Wells
- QA Physics, Royal Marsden Hospital, London, United Kingdom
| | - Stephanie Witts
- The Institute of Cancer Research Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Emma Hall
- The Institute of Cancer Research Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
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Wong KH, Panek R, Dunlop A, Mcquaid D, Riddell A, Welsh LC, Murray I, Koh DM, Leach MO, Bhide SA, Nutting CM, Oyen WJ, Harrington KJ, Newbold KL. Changes in multimodality functional imaging parameters early during chemoradiation predict treatment response in patients with locally advanced head and neck cancer. Eur J Nucl Med Mol Imaging 2018; 45:759-767. [PMID: 29164301 PMCID: PMC5978912 DOI: 10.1007/s00259-017-3890-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 11/13/2017] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To assess the optimal timing and predictive value of early intra-treatment changes in multimodality functional and molecular imaging (FMI) parameters as biomarkers for clinical remission in patients receiving chemoradiation for head and neck squamous cell carcinoma (HNSCC). METHODS Thirty-five patients with stage III-IVb (AJCC 7th edition) HNSCC prospectively underwent 18F-FDG-PET/CT, and diffusion-weighted (DW), dynamic contrast-enhanced (DCE) and susceptibility-weighted MRI at baseline, week 1 and week 2 of chemoradiation. Patients with evidence of persistent or recurrent disease during follow-up were classed as non-responders. Changes in FMI parameters at week 1 and week 2 were compared between responders and non-responders with the Mann-Whitney U test. The significance threshold was set at a p value of <0.05. RESULTS There were 27 responders and 8 non-responders. Responders showed a greater reduction in PET-derived tumor total lesion glycolysis (TLG40%; p = 0.007) and maximum standardized uptake value (SUVmax; p = 0.034) after week 1 than non-responders but these differences were absent by week 2. In contrast, it was not until week 2 that MRI-derived parameters were able to discriminate between the two groups: larger fractional increases in primary tumor apparent diffusion coefficient (ADC; p < 0.001), volume transfer constant (Ktrans; p = 0.012) and interstitial space volume fraction (Ve; p = 0.047) were observed in responders versus non-responders. ADC was the most powerful predictor (∆ >17%, AUC 0.937). CONCLUSION Early intra-treatment changes in FDG-PET, DW and DCE MRI-derived parameters are predictive of ultimate response to chemoradiation in HNSCC. However, the optimal timing for assessment with FDG-PET parameters (week 1) differed from MRI parameters (week 2). This highlighted the importance of scanning time points for the design of FMI risk-stratified interventional studies.
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Affiliation(s)
- Kee H Wong
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, SM2 5PT, UK.
- Radiotherapy and Imaging Division, The Institute of Cancer Research, London, UK.
| | - Rafal Panek
- Radiotherapy and Imaging Division, The Institute of Cancer Research, London, UK
| | - Alex Dunlop
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, SM2 5PT, UK
- Radiotherapy and Imaging Division, The Institute of Cancer Research, London, UK
| | - Dualta Mcquaid
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, SM2 5PT, UK
| | - Angela Riddell
- Clinical Radiology, The Royal Marsden NHS Foundation Trust, Sutton, UK
| | - Liam C Welsh
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, SM2 5PT, UK
- Radiotherapy and Imaging Division, The Institute of Cancer Research, London, UK
| | - Iain Murray
- Nuclear Medicine, The Royal Marsden NHS Foundation Trust, Sutton, UK
| | - Dow-Mu Koh
- Radiotherapy and Imaging Division, The Institute of Cancer Research, London, UK
- Clinical Radiology, The Royal Marsden NHS Foundation Trust, Sutton, UK
| | - Martin O Leach
- Radiotherapy and Imaging Division, The Institute of Cancer Research, London, UK
- CRUK Cancer Imaging Centre, The Institute of Cancer Research and the Royal Marsden NHS Foundation Trust, London, UK
| | - Shreerang A Bhide
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, SM2 5PT, UK
- Radiotherapy and Imaging Division, The Institute of Cancer Research, London, UK
| | - Christopher M Nutting
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, SM2 5PT, UK
- Radiotherapy and Imaging Division, The Institute of Cancer Research, London, UK
| | - Wim J Oyen
- Radiotherapy and Imaging Division, The Institute of Cancer Research, London, UK
- Nuclear Medicine, The Royal Marsden NHS Foundation Trust, Sutton, UK
| | - Kevin J Harrington
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, SM2 5PT, UK
- Radiotherapy and Imaging Division, The Institute of Cancer Research, London, UK
| | - Kate L Newbold
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, SM2 5PT, UK
- Radiotherapy and Imaging Division, The Institute of Cancer Research, London, UK
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10
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Gurney-Champion OJ, McQuaid D, Dunlop A, Wong KH, Welsh LC, Riddell AM, Koh DM, Oelfke U, Leach MO, Nutting CM, Bhide SA, Harrington KJ, Panek R, Newbold KL. MRI-based Assessment of 3D Intrafractional Motion of Head and Neck Cancer for Radiation Therapy. Int J Radiat Oncol Biol Phys 2018; 100:306-316. [PMID: 29229323 PMCID: PMC5777665 DOI: 10.1016/j.ijrobp.2017.10.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 09/14/2017] [Accepted: 10/03/2017] [Indexed: 01/25/2023]
Abstract
PURPOSE To determine the 3-dimensional (3D) intrafractional motion of head and neck squamous cell carcinoma (HNSCC). METHODS AND MATERIALS Dynamic contrast-enhanced magnetic resonance images from 56 patients with HNSCC in the treatment position were analyzed. Dynamic contrast-enhanced magnetic resonance imaging consisted of 3D images acquired every 2.9 seconds for 4 minutes 50 seconds. Intrafractional tumor motion was studied in the 3 minutes 43 seconds of images obtained after initial contrast enhancement. To assess tumor motion, rigid registration (translations only) was performed using a region of interest (ROI) mask around the tumor. The results were compared with bulk body motion from registration to all voxels. Motion was split into systematic motion and random motion. Correlations between the tumor site and random motion were tested. The within-subject coefficient of variation was determined from 8 patients with repeated baseline measures. Random motion was also assessed at the end of the first week (38 patients) and second week (25 patients) of radiation therapy to investigate trends of motion. RESULTS Tumors showed irregular occasional rapid motion (eg, swallowing or coughing), periodic intermediate motion (respiration), and slower systematic drifts throughout treatment. For 95% of the patients, displacements due to systematic and random motion were <1.4 mm and <2.1 mm, respectively, 95% of the time. The motion without an ROI mask was significantly (P<.0001, Wilcoxon signed rank test) less than the motion with an ROI mask, indicating that tumors can move independently from the bony anatomy. Tumor motion was significantly (P=.005, Mann-Whitney U test) larger in the hypopharynx and larynx than in the oropharynx. The within-subject coefficient of variation for random motion was 0.33. The average random tumor motion did not increase notably during the first 2 weeks of treatment. CONCLUSIONS The 3D intrafractional tumor motion of HNSCC is small, with systematic motion <1.4 mm and random motion <2.1 mm 95% of the time.
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Affiliation(s)
- Oliver J Gurney-Champion
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK.
| | - Dualta McQuaid
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - Alex Dunlop
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - Kee H Wong
- Department of Clinical Oncology, The Royal Marsden NHS Foundation Trust, London, UK
| | - Liam C Welsh
- Department of Clinical Oncology, The Royal Marsden NHS Foundation Trust, London, UK
| | - Angela M Riddell
- Department of Radiology, The Royal Marsden NHS Foundation Trust, London, UK
| | - Dow-Mu Koh
- Department of Radiology, The Royal Marsden NHS Foundation Trust, London, UK
| | - Uwe Oelfke
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - Martin O Leach
- CR UK Cancer Imaging Centre, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - Christopher M Nutting
- Joint Department of Radiotherapy, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - Shreerang A Bhide
- Joint Department of Radiotherapy, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - Kevin J Harrington
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - Rafal Panek
- Department of Medical Physics and Clinical Engineering, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Kate L Newbold
- Department of Clinical Oncology, The Royal Marsden NHS Foundation Trust, London, UK
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11
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Panek R, Welsh L, Baker LCJ, Schmidt MA, Wong KH, Riddell AM, Koh DM, Dunlop A, Mcquaid D, d'Arcy JA, Bhide SA, Harrington KJ, Nutting CM, Hopkinson G, Richardson C, Box C, Eccles SA, Leach MO, Robinson SP, Newbold KL. Noninvasive Imaging of Cycling Hypoxia in Head and Neck Cancer Using Intrinsic Susceptibility MRI. Clin Cancer Res 2017; 23:4233-4241. [PMID: 28314789 PMCID: PMC5516915 DOI: 10.1158/1078-0432.ccr-16-1209] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 07/19/2016] [Accepted: 03/03/2017] [Indexed: 01/13/2023]
Abstract
Purpose: To evaluate intrinsic susceptibility (IS) MRI for the identification of cycling hypoxia, and the assessment of its extent and spatial distribution, in head and neck squamous cell carcinoma (HNSCC) xenografts and patients.Experimental Design: Quantitation of the transverse relaxation rate, R2*, which is sensitive to paramagnetic deoxyhemoglobin, using serial IS-MRI acquisitions, was used to monitor temporal oscillations in levels of paramagnetic deoxyhemoglobin in human CALR xenografts and patients with HNSCC at 3T. Autocovariance and power spectrum analysis of variations in R2* was performed for each imaged voxel, to assess statistical significance and frequencies of cycling changes in tumor blood oxygenation. Pathologic correlates with tumor perfusion (Hoechst 33342), hypoxia (pimonidazole), and vascular density (CD31) were sought in the xenografts, and dynamic contrast-enhanced (DCE) MRI was used to assess patient tumor vascularization. The prevalence of fluctuations within patient tumors, DCE parameters, and treatment outcome were reported.Results: Spontaneous R2* fluctuations with a median periodicity of 15 minutes were detected in both xenografts and patient tumors. Spatially, these fluctuations were predominantly associated with regions of heterogeneous perfusion and hypoxia in the CALR xenografts. In patients, R2* fluctuations spatially correlated with regions of lymph nodes with low Ktrans values, typically in the vicinity of necrotic cores.Conclusions: IS-MRI can be used to monitor variations in levels of paramagnetic deoxyhemoglobin, associated with cycling hypoxia. The presence of such fluctuations may be linked with impaired tumor vasculature, the presence of which may impact treatment outcome. Clin Cancer Res; 23(15); 4233-41. ©2017 AACR.
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Affiliation(s)
- Rafal Panek
- CR-UK and EPSRC Cancer Imaging Centre, London, United Kingdom
- Institute of Cancer Research, London, United Kingdom
- Royal Marsden Hospital, London, United Kingdom
| | - Liam Welsh
- Institute of Cancer Research, London, United Kingdom
- Royal Marsden Hospital, London, United Kingdom
| | - Lauren C J Baker
- CR-UK and EPSRC Cancer Imaging Centre, London, United Kingdom
- Institute of Cancer Research, London, United Kingdom
| | - Maria A Schmidt
- CR-UK and EPSRC Cancer Imaging Centre, London, United Kingdom
- Institute of Cancer Research, London, United Kingdom
- Royal Marsden Hospital, London, United Kingdom
| | - Kee H Wong
- Institute of Cancer Research, London, United Kingdom
- Royal Marsden Hospital, London, United Kingdom
| | - Angela M Riddell
- CR-UK and EPSRC Cancer Imaging Centre, London, United Kingdom
- Institute of Cancer Research, London, United Kingdom
- Royal Marsden Hospital, London, United Kingdom
| | - Dow-Mu Koh
- CR-UK and EPSRC Cancer Imaging Centre, London, United Kingdom
- Institute of Cancer Research, London, United Kingdom
- Royal Marsden Hospital, London, United Kingdom
| | - Alex Dunlop
- Institute of Cancer Research, London, United Kingdom
- Royal Marsden Hospital, London, United Kingdom
| | - Dualta Mcquaid
- Institute of Cancer Research, London, United Kingdom
- Royal Marsden Hospital, London, United Kingdom
| | - James A d'Arcy
- CR-UK and EPSRC Cancer Imaging Centre, London, United Kingdom
- Institute of Cancer Research, London, United Kingdom
- Royal Marsden Hospital, London, United Kingdom
| | - Shreerang A Bhide
- Institute of Cancer Research, London, United Kingdom
- Royal Marsden Hospital, London, United Kingdom
| | - Kevin J Harrington
- Institute of Cancer Research, London, United Kingdom
- Royal Marsden Hospital, London, United Kingdom
| | | | | | | | - Carol Box
- Institute of Cancer Research, London, United Kingdom
| | | | - Martin O Leach
- CR-UK and EPSRC Cancer Imaging Centre, London, United Kingdom.
- Institute of Cancer Research, London, United Kingdom
- Royal Marsden Hospital, London, United Kingdom
| | - Simon P Robinson
- CR-UK and EPSRC Cancer Imaging Centre, London, United Kingdom
- Institute of Cancer Research, London, United Kingdom
| | - Kate L Newbold
- Institute of Cancer Research, London, United Kingdom
- Royal Marsden Hospital, London, United Kingdom
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12
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Richards TM, Hurley T, Grove L, Harrington KJ, Carpenter GH, Proctor GB, Nutting CM. The effect of parotid gland-sparing intensity-modulated radiotherapy on salivary composition, flow rate and xerostomia measures. Oral Dis 2017; 23:990-1000. [PMID: 28434191 DOI: 10.1111/odi.12686] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 03/11/2017] [Accepted: 04/05/2017] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To describe parotid gland (PG) saliva organic and inorganic composition and flow rate changes, after curative intensity-modulated radiotherapy (IMRT) for head and neck cancer (HNC), and analyse the relationship between PG saliva analytes and xerostomia measures. METHODS AND MATERIALS Twenty-six patients recruited to five prospective phase 2 or 3 trials which assessed toxicity and efficacy of IMRT by HNC subsite, provided longitudinal PG saliva. Salivary flow rate, and subjective and objective xerostomia measures were prospectively collected and saliva tested for inorganic and organic analytes. Statistical comparisons of longitudinal analyte changes and analysis for a relationship between dichotomized xerostomia score and saliva analytes were performed. RESULTS One hundred and forty-two PG saliva samples from 26 patients were analysed. At 3-6 months after IMRT, stimulated and unstimulated saliva showed significantly decreased flow rate, total protein (TP) secretion rate, phosphate concentration and increased lactoferrin (LF) concentration. Stimulated saliva alone had elevated LF secretion rate and beta-2-microglobulin (B2 M) concentration with decreased calcium (Ca2+ ) and magnesium (Mg2+ ) concentrations and Ca2+ secretion rate. At >12 months, under stimulated and unstimulated conditions, increased LF concentration and decreased Mg2+ and phosphate concentration persisted and, in stimulated saliva, there was decreased potassium (K+ ) and Mg2+ concentration. Unstimulated TP secretion rate was lower in the presence of high-grade xerostomia. Otherwise, no relationship between xerostomia grade and PG salivary flow rate, TP and Ca2+ secretion rate was found. CONCLUSION Fewer significant differences in PG saliva analytes >12 months after IMRT indicate good functional recovery. Residual xerostomia after IMRT will only be further reduced by addressing the sparing of subsites of the PG or other salivary gland tissues, in addition to the PG.
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Affiliation(s)
- T M Richards
- Head and Neck Unit, Royal Marsden Hospitals NHS Foundation Trust, London, Surrey, UK
| | - T Hurley
- Head and Neck Unit, Royal Marsden Hospitals NHS Foundation Trust, London, Surrey, UK
| | - L Grove
- Head and Neck Unit, Royal Marsden Hospitals NHS Foundation Trust, London, Surrey, UK
| | - K J Harrington
- Head and Neck Unit, Royal Marsden Hospitals NHS Foundation Trust, London, Surrey, UK.,The Institute of Cancer Research, London, UK
| | - G H Carpenter
- Mucosal & Salivary Biology Division, Dental Institute, Kings College London, London, UK
| | - G B Proctor
- Mucosal & Salivary Biology Division, Dental Institute, Kings College London, London, UK
| | - C M Nutting
- Head and Neck Unit, Royal Marsden Hospitals NHS Foundation Trust, London, Surrey, UK.,The Institute of Cancer Research, London, UK
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13
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Wong KH, Panek R, Bhide SA, Nutting CM, Harrington KJ, Newbold KL. The emerging potential of magnetic resonance imaging in personalizing radiotherapy for head and neck cancer: an oncologist's perspective. Br J Radiol 2017; 90:20160768. [PMID: 28256151 DOI: 10.1259/bjr.20160768] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Head and neck cancer (HNC) is a challenging tumour site for radiotherapy delivery owing to its complex anatomy and proximity to organs at risk (OARs) such as the spinal cord and optic apparatus. Despite significant advances in radiotherapy planning techniques, radiation-induced morbidities remain substantial. Further improvement would require high-quality imaging and tailored radiotherapy based on intratreatment response. For these reasons, the use of MRI in radiotherapy planning for HNC is rapidly gaining popularity. MRI provides superior soft-tissue contrast in comparison with CT, allowing better definition of the tumour and OARs. The lack of additional radiation exposure is another attractive feature for intratreatment monitoring. In addition, advanced MRI techniques such as diffusion-weighted, dynamic contrast-enhanced and intrinsic susceptibility-weighted MRI techniques are capable of characterizing tumour biology further by providing quantitative functional parameters such as tissue cellularity, vascular permeability/perfusion and hypoxia. These functional parameters are known to have radiobiological relevance, which potentially could guide treatment adaptation based on their changes prior to or during radiotherapy. In this article, we first present an overview of the applications of anatomical MRI sequences in head and neck radiotherapy, followed by the potentials and limitations of functional MRI sequences in personalizing therapy.
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Affiliation(s)
- Kee H Wong
- 1 Head and neck unit, The Royal Marsden Hospital, London, UK.,2 Radiotherapy and imaging, The Institute of Cancer Research, London, UK
| | - Rafal Panek
- 1 Head and neck unit, The Royal Marsden Hospital, London, UK.,2 Radiotherapy and imaging, The Institute of Cancer Research, London, UK
| | - Shreerang A Bhide
- 1 Head and neck unit, The Royal Marsden Hospital, London, UK.,2 Radiotherapy and imaging, The Institute of Cancer Research, London, UK
| | - Christopher M Nutting
- 1 Head and neck unit, The Royal Marsden Hospital, London, UK.,2 Radiotherapy and imaging, The Institute of Cancer Research, London, UK
| | - Kevin J Harrington
- 1 Head and neck unit, The Royal Marsden Hospital, London, UK.,2 Radiotherapy and imaging, The Institute of Cancer Research, London, UK
| | - Katie L Newbold
- 1 Head and neck unit, The Royal Marsden Hospital, London, UK.,2 Radiotherapy and imaging, The Institute of Cancer Research, London, UK
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14
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Dean JA, Welsh LC, Wong KH, Aleksic A, Dunne E, Islam MR, Patel A, Patel P, Petkar I, Phillips I, Sham J, Schick U, Newbold KL, Bhide SA, Harrington KJ, Nutting CM, Gulliford SL. Normal Tissue Complication Probability (NTCP) Modelling of Severe Acute Mucositis using a Novel Oral Mucosal Surface Organ at Risk. Clin Oncol (R Coll Radiol) 2017; 29:263-273. [PMID: 28057404 PMCID: PMC6175048 DOI: 10.1016/j.clon.2016.12.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 10/20/2016] [Accepted: 11/01/2016] [Indexed: 12/23/2022]
Abstract
AIMS A normal tissue complication probability (NTCP) model of severe acute mucositis would be highly useful to guide clinical decision making and inform radiotherapy planning. We aimed to improve upon our previous model by using a novel oral mucosal surface organ at risk (OAR) in place of an oral cavity OAR. MATERIALS AND METHODS Predictive models of severe acute mucositis were generated using radiotherapy dose to the oral cavity OAR or mucosal surface OAR and clinical data. Penalised logistic regression and random forest classification (RFC) models were generated for both OARs and compared. Internal validation was carried out with 100-iteration stratified shuffle split cross-validation, using multiple metrics to assess different aspects of model performance. Associations between treatment covariates and severe mucositis were explored using RFC feature importance. RESULTS Penalised logistic regression and RFC models using the oral cavity OAR performed at least as well as the models using mucosal surface OAR. Associations between dose metrics and severe mucositis were similar between the mucosal surface and oral cavity models. The volumes of oral cavity or mucosal surface receiving intermediate and high doses were most strongly associated with severe mucositis. CONCLUSIONS The simpler oral cavity OAR should be preferred over the mucosal surface OAR for NTCP modelling of severe mucositis. We recommend minimising the volume of mucosa receiving intermediate and high doses, where possible.
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Affiliation(s)
- J A Dean
- Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK.
| | - L C Welsh
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - K H Wong
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - A Aleksic
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - E Dunne
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - M R Islam
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - A Patel
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - P Patel
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - I Petkar
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - I Phillips
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - J Sham
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - U Schick
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - K L Newbold
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK; Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | - S A Bhide
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK; Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | - K J Harrington
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK; Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | - C M Nutting
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK; Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | - S L Gulliford
- Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
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15
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Dillon MT, Barker HE, Pedersen M, Hafsi H, Bhide SA, Newbold KL, Nutting CM, McLaughlin M, Harrington KJ. Radiosensitization by the ATR Inhibitor AZD6738 through Generation of Acentric Micronuclei. Mol Cancer Ther 2017; 16:25-34. [PMID: 28062704 PMCID: PMC5302142 DOI: 10.1158/1535-7163.mct-16-0239] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 10/21/2016] [Accepted: 11/01/2016] [Indexed: 11/16/2022]
Abstract
AZD6738 is an orally active ATR inhibitor (ATRi) currently in phase I clinical trials. We found in vitro growth inhibitory activity of this ATRi in a panel of human cancer cell lines. We demonstrated radiosensitization by AZD6738 to single radiation fractions in multiple cancer cell lines independent of both p53 and BRCA2 status by the clonogenic assay. Radiosensitization by AZD6738 to clinically relevant doses of fractionated radiation was demonstrated in vitro using a 3D tumor spheroid model and, in vivo, AZD6738 radiosensitized by abrogating the radiation-induced G2 cell-cycle checkpoint and inhibiting homologous recombination. Mitosis with damaged DNA resulted in mitotic catastrophe as measured by micronucleus formation by live-cell fluorescent-ubiquitination cell-cycle imaging of cell-cycle progression and nuclear morphology. Induction of micronuclei was significantly more prominent for AZD6738 compared with inhibition of the downstream kinase CHK1 alone at isoeffective doses. Micronuclei were characterized as acentric chromosomal fragments, which displayed characteristics of increased DNA damage and cell-cycle dyssynchrony when compared with the primary nucleus. Mol Cancer Ther; 16(1); 25-34. ©2016 AACR.
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Affiliation(s)
- Magnus T. Dillon
- Targeted Therapy Team, Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | - Holly E. Barker
- Targeted Therapy Team, Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | - Malin Pedersen
- Targeted Therapy Team, Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | - Hind Hafsi
- Targeted Therapy Team, Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | | | | | | | - Martin McLaughlin
- Targeted Therapy Team, Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | - Kevin J. Harrington
- Targeted Therapy Team, Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
- The Royal Marsden Hospital, London, UK
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16
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Schache AG, Powell NG, Cuschieri KS, Robinson M, Leary S, Mehanna H, Rapozo D, Long A, Cubie H, Junor E, Monaghan H, Harrington KJ, Nutting CM, Schick U, Lau AS, Upile N, Sheard J, Brougham K, West CML, Oguejiofor K, Thomas S, Ness AR, Pring M, Thomas GJ, King EV, McCance DJ, James JA, Moran M, Sloan P, Shaw RJ, Evans M, Jones TM. HPV-Related Oropharynx Cancer in the United Kingdom: An Evolution in the Understanding of Disease Etiology. Cancer Res 2016; 76:6598-6606. [PMID: 27569214 PMCID: PMC9158514 DOI: 10.1158/0008-5472.can-16-0633] [Citation(s) in RCA: 115] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Revised: 05/27/2016] [Accepted: 07/17/2016] [Indexed: 11/16/2022]
Abstract
A rising incidence of oropharyngeal squamous cell carcinoma (OPSCC) incidence has occurred throughout the developed world, where it has been attributed to an increasing impact of human papillomavirus (HPV) on disease etiology. This report presents the findings of a multicenter cross-sectional retrospective study aimed at determining the proportion of HPV-positive and HPV-negative OPSCC within the United Kingdom. Archival tumor tissue blocks from 1,602 patients previously diagnosed with OPSCC (2002-2011) were collated from 11 centers. HPV status was determined with three validated commercial tests to provide valid data for 1,474 cases in total. Corresponding national incidence data from the same decade were obtained from UK Cancer registries. The overall proportion of HPV+ OPSCC between 2002 and 2011 was 51.8% [95% confidence interval (CI), 49.3-54.4], and this remained unchanged throughout the decade [unadjusted RR = 1.00 (95% CI, 0.99-1.02)]. However, over the same period, the incidence of OPSCC in the broader UK population underwent a 2-fold increase [age-standardized rate 2002: 2.1 (95% CI, 1.9-2.2); 2011: 4.1 (95% CI, 4.0-4.3)]. Although the number of OPSCCs diagnosed within the United Kingdom from 2002 to 2011 nearly doubled, the proportion of HPV+ cases remained static at approximately 50%. Our results argue that the rapidly increasing incidence of OPSCC in the United Kingdom cannot be solely attributable to the influence of HPV. The parallel increase in HPV+ and HPV- cases we documented warrants further investigation, so that appropriate future prevention strategies for both types of disease can be implemented. Cancer Res; 76(22); 6598-606. ©2016 AACR.
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Affiliation(s)
- Andrew G Schache
- Department of Molecular & Clinical Cancer Medicine, Northwest Cancer Research Centre, University of Liverpool, Liverpool, United Kingdom
- Head & Neck Unit, University Hospital Aintree, Liverpool, United Kingdom
| | - Ned G Powell
- Institute of Cancer and Genetics, Cardiff University School of Medicine, Cardiff, United Kingdom
| | - Kate S Cuschieri
- Scottish Human Papillomavirus Reference Laboratory, Royal Infirmary of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Max Robinson
- Centre for Oral Health Research, Newcastle University, Newcastle, United Kingdom
| | - Sam Leary
- Biomedical Research Unit in Nutrition, Diet and Lifestyle, School of Oral and Dental Sciences, University Hospitals Bristol, Bristol, United Kingdom
| | - Hisham Mehanna
- Institute of Head and Neck Studies and Education (InHANSE), College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Davy Rapozo
- Brazilian National Cancer Institute, Rio de Janeiro, Brazil
| | - Anna Long
- Cellular Pathology, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle, United Kingdom
| | - Heather Cubie
- Scottish Human Papillomavirus Reference Laboratory, Royal Infirmary of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Elizabeth Junor
- Edinburgh Cancer Research Centre, Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Hannah Monaghan
- Pathology Department, Royal Infirmary of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Kevin J Harrington
- NIHR Biomedical Research Centre, The Institute of Cancer Research, London, United Kingdom
- Royal Marsden NHS Foundation Trust, London, United Kingdom
| | | | - Ulrike Schick
- NIHR Biomedical Research Centre, The Institute of Cancer Research, London, United Kingdom
- Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Andy S Lau
- Department of Molecular & Clinical Cancer Medicine, Northwest Cancer Research Centre, University of Liverpool, Liverpool, United Kingdom
- Head & Neck Unit, University Hospital Aintree, Liverpool, United Kingdom
| | - Navdeep Upile
- Department of Molecular & Clinical Cancer Medicine, Northwest Cancer Research Centre, University of Liverpool, Liverpool, United Kingdom
- Head & Neck Unit, University Hospital Aintree, Liverpool, United Kingdom
| | - Jon Sheard
- Pathology Department, Aintree University Hospital NHS Foundation Trust, Liverpool, United Kingdom
| | - Kath Brougham
- Pathology Department, Aintree University Hospital NHS Foundation Trust, Liverpool, United Kingdom
| | - Catharine M L West
- Institute of Cancer Sciences, University of Manchester, Manchester, United Kingdom
| | - Ken Oguejiofor
- Institute of Cancer Sciences, University of Manchester, Manchester, United Kingdom
| | - Steve Thomas
- School of Oral & Dental Sciences, University of Bristol, Bristol, United Kingdom
| | - Andy R Ness
- Biomedical Research Unit in Nutrition, Diet and Lifestyle, School of Oral and Dental Sciences, University Hospitals Bristol, Bristol, United Kingdom
| | - Miranda Pring
- School of Oral & Dental Sciences, University of Bristol, Bristol, United Kingdom
| | - Gareth J Thomas
- Cancer Sciences Unit, University of Southampton, Southampton, United Kingdom
| | - Emma V King
- Poole Hospital NHS Foundation Trust, Poole, United Kingdom
| | - Dennis J McCance
- Department of Pathology, School of Medicine, University of New Mexico, Albuquerque, New Mexico
| | - Jacqueline A James
- Northern Ireland Molecular Pathology Laboratory, Centre for Cancer Research and Cell Biology, Belfast, Northern Ireland
| | | | - Phil Sloan
- Centre for Oral Health Research, Newcastle University, Newcastle, United Kingdom
| | - Richard J Shaw
- Department of Molecular & Clinical Cancer Medicine, Northwest Cancer Research Centre, University of Liverpool, Liverpool, United Kingdom
- Head & Neck Unit, University Hospital Aintree, Liverpool, United Kingdom
| | | | - Terry M Jones
- Department of Molecular & Clinical Cancer Medicine, Northwest Cancer Research Centre, University of Liverpool, Liverpool, United Kingdom.
- Head & Neck Unit, University Hospital Aintree, Liverpool, United Kingdom
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Rupani A, Hughes OR, Watkinson J, Nutting CM, Thway K. Metastatic Papillary Thyroid Carcinoma With Adjacent BRAF (V600E)-Mutated Squamous Cell Carcinoma. Int J Surg Pathol 2016; 25:243-245. [PMID: 27829211 DOI: 10.1177/1066896916674811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Panek R, Schmidt MA, Borri M, Koh DM, Riddell A, Welsh L, Dunlop A, Powell C, Bhide SA, Nutting CM, Harrington KJ, Newbold KL, Leach MO. Time-resolved angiography with stochastic trajectories for dynamic contrast-enhanced MRI in head and neck cancer: Are pharmacokinetic parameters affected? Med Phys 2016; 43:6024. [PMID: 27806585 DOI: 10.1118/1.4964795] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 09/26/2016] [Accepted: 09/30/2016] [Indexed: 12/31/2022] Open
Abstract
PURPOSE To investigate the effects of different time-resolved angiography with stochastic trajectories (TWIST) k-space undersampling schemes on calculated pharmacokinetic dynamic contrast-enhanced (DCE) vascular parameters. METHODS A digital perfusion phantom was employed to simulate effects of TWIST on characteristics of signal changes in DCE. Furthermore, DCE-MRI was acquired without undersampling in a group of patients with head and neck squamous cell carcinoma and used to simulate a range of TWIST schemes. Errors were calculated as differences between reference and TWIST-simulated DCE parameters. Parametrical error maps were used to display the averaged results from all tumors. RESULTS For a relatively wide range of undersampling schemes, errors in pharmacokinetic parameters due to TWIST were under 10% for the volume transfer constant, Ktrans, and total extracellular extravascular space volume, Ve. TWIST induced errors in the total blood plasma volume, Vp, were the largest observed, and these were inversely dependent on the area of the fully sampled k-space. The magnitudes of errors were not correlated with Ktrans, Vp and weakly correlated with Ve. CONCLUSIONS The authors demonstrated methods to validate and optimize k-space view-sharing techniques for pharmacokinetic DCE studies using a range of clinically relevant spatial and temporal patient derived data. The authors found a range of undersampling patterns for which the TWIST sequence can be reliably used in pharmacokinetic DCE-MRI. The parameter maps created in the study can help to make a decision between temporal and spatial resolution demands and the quality of enhancement curve characterization.
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Affiliation(s)
- Rafal Panek
- CR-UK Cancer Imaging Centre, London SM2 5PT, United Kingdom; The Institute of Cancer Research, London SM2 5PT, United Kingdom; and The Royal Marsden NHS Trust, London SM2 5PT, United Kingdom
| | - Maria A Schmidt
- CR-UK Cancer Imaging Centre, London SM2 5PT, United Kingdom; The Institute of Cancer Research, London SM2 5PT, United Kingdom; and The Royal Marsden NHS Trust, London SM2 5PT, United Kingdom
| | - Marco Borri
- CR-UK Cancer Imaging Centre, London SM2 5PT, United Kingdom; The Institute of Cancer Research, London SM2 5PT, United Kingdom; and The Royal Marsden NHS Trust, London SM2 5PT, United Kingdom
| | - Dow-Mu Koh
- The Institute of Cancer Research, London SM2 5PT, United Kingdom and The Royal Marsden NHS Trust, London SM2 5PT, United Kingdom
| | - Angela Riddell
- The Royal Marsden NHS Trust, London SM2 5PT, United Kingdom
| | - Liam Welsh
- The Institute of Cancer Research, London SM2 5PT, United Kingdom and The Royal Marsden NHS Trust, London SM2 5PT, United Kingdom
| | - Alex Dunlop
- The Institute of Cancer Research, London SM2 5PT, United Kingdom and The Royal Marsden NHS Trust, London SM2 5PT, United Kingdom
| | - Ceri Powell
- The Institute of Cancer Research, London SM2 5PT, United Kingdom
| | - Shreerang A Bhide
- The Institute of Cancer Research, London SM2 5PT, United Kingdom and The Royal Marsden NHS Trust, London SM2 5PT, United Kingdom
| | - Christopher M Nutting
- The Institute of Cancer Research, London SM2 5PT, United Kingdom and The Royal Marsden NHS Trust, London SM2 5PT, United Kingdom
| | - Kevin J Harrington
- The Institute of Cancer Research, London SM2 5PT, United Kingdom and The Royal Marsden NHS Trust, London SM2 5PT, United Kingdom
| | - Kate L Newbold
- The Institute of Cancer Research, London SM2 5PT, United Kingdom and The Royal Marsden NHS Trust, London SM2 5PT, United Kingdom
| | - Martin O Leach
- CR-UK Cancer Imaging Centre, London SM2 5PT, United Kingdom; The Institute of Cancer Research, London SM2 5PT, United Kingdom; and The Royal Marsden NHS Trust, London SM2 5PT, United Kingdom
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Petkar I, Rooney K, Roe JWG, Patterson JM, Bernstein D, Tyler JM, Emson MA, Morden JP, Mertens K, Miles E, Beasley M, Roques T, Bhide SA, Newbold KL, Harrington KJ, Hall E, Nutting CM. DARS: a phase III randomised multicentre study of dysphagia- optimised intensity- modulated radiotherapy (Do-IMRT) versus standard intensity- modulated radiotherapy (S-IMRT) in head and neck cancer. BMC Cancer 2016; 16:770. [PMID: 27716125 PMCID: PMC5052945 DOI: 10.1186/s12885-016-2813-0] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 09/26/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Persistent dysphagia following primary chemoradiation (CRT) for head and neck cancers can have a devastating impact on patients' quality of life. Single arm studies have shown that the dosimetric sparing of critical swallowing structures such as the pharyngeal constrictor muscle and supraglottic larynx can translate to better functional outcomes. However, there are no current randomised studies to confirm the benefits of such swallow sparing strategies. The aim of Dysphagia/Aspiration at risk structures (DARS) trial is to determine whether reducing the dose to the pharyngeal constrictors with dysphagia-optimised intensity- modulated radiotherapy (Do-IMRT) will lead to an improvement in long- term swallowing function without having any detrimental impact on disease-specific survival outcomes. METHODS/DESIGN The DARS trial (CRUK/14/014) is a phase III multicentre randomised controlled trial (RCT) for patients undergoing primary (chemo) radiotherapy for T1-4, N0-3, M0 pharyngeal cancers. Patients will be randomised (1:1 ratio) to either standard IMRT (S-IMRT) or Do-IMRT. Radiotherapy doses will be the same in both groups; however in patients allocated to Do-IMRT, irradiation of the pharyngeal musculature will be reduced by delivering IMRT identifying the pharyngeal muscles as organs at risk. The primary endpoint of the trial is the difference in the mean MD Anderson Dysphagia Inventory (MDADI) composite score, a patient-reported outcome, measured at 12 months post radiotherapy. Secondary endpoints include prospective and longitudinal evaluation of swallow outcomes incorporating a range of subjective and objective assessments, quality of life measures, loco-regional control and overall survival. Patients and speech and language therapists (SLTs) will both be blinded to treatment allocation arm to minimise outcome-reporting bias. DISCUSSION DARS is the first RCT investigating the effect of swallow sparing strategies on improving long-term swallowing outcomes in pharyngeal cancers. An integral part of the study is the multidimensional approach to swallowing assessment, providing robust data for the standardisation of future swallow outcome measures. A translational sub- study, which may lead to the development of future predictive and prognostic biomarkers, is also planned. TRIAL REGISTRATION This study is registered with the International Standard Randomised Controlled Trial register, ISRCTN25458988 (04/01/2016).
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Affiliation(s)
- Imran Petkar
- The Royal Marsden NHS Foundation Trust, Fulham Road, London, SW3 6JJ UK
- The Institute of Cancer Research (ICR), 123 Old Brompton Road, London, SW7 3RP UK
| | - Keith Rooney
- Northern Ireland Cancer Centre, Belfast Health and Social Care Trust, Belfast City Hospital, Lisburn Road, Belfast, BT9 7AB UK
| | - Justin W. G. Roe
- The Royal Marsden NHS Foundation Trust, Fulham Road, London, SW3 6JJ UK
| | - Joanne M. Patterson
- Speech and Language Therapy Department, Sunderland City Hospitals NHS Foundation Trust, Kayll Road, Sunderland, SR4 7TP UK
- Institute of Health and Society, University of Newcastle, Newcastle upon Tyne, NE1 7RU UK
| | - David Bernstein
- The Royal Marsden NHS Foundation Trust, Fulham Road, London, SW3 6JJ UK
| | - Justine M. Tyler
- The Royal Marsden NHS Foundation Trust, Fulham Road, London, SW3 6JJ UK
| | - Marie A. Emson
- The Institute of Cancer Research (ICR), 123 Old Brompton Road, London, SW7 3RP UK
| | - James P. Morden
- The Institute of Cancer Research (ICR), 123 Old Brompton Road, London, SW7 3RP UK
| | - Kathrin Mertens
- The Institute of Cancer Research (ICR), 123 Old Brompton Road, London, SW7 3RP UK
| | - Elizabeth Miles
- Mount Vernon Hospital, Rickmansworth Road, Northwood, HA6 2RN UK
| | - Matthew Beasley
- University Hospitals Bristol, Horfield Road, Bristol, BS2 8ED UK
| | - Tom Roques
- Norfolk and Norwich University Hospital NHS Trust, Colney Lane, Norwich, NR4 7UY UK
| | - Shreerang A. Bhide
- The Royal Marsden NHS Foundation Trust, Fulham Road, London, SW3 6JJ UK
- The Institute of Cancer Research (ICR), 123 Old Brompton Road, London, SW7 3RP UK
| | - Kate L. Newbold
- The Royal Marsden NHS Foundation Trust, Fulham Road, London, SW3 6JJ UK
| | - Kevin J. Harrington
- The Royal Marsden NHS Foundation Trust, Fulham Road, London, SW3 6JJ UK
- The Institute of Cancer Research (ICR), 123 Old Brompton Road, London, SW7 3RP UK
| | - Emma Hall
- The Institute of Cancer Research (ICR), 123 Old Brompton Road, London, SW7 3RP UK
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20
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Miah AB, Gulliford SL, Morden J, Newbold KL, Bhide SA, Zaidi SH, Hall E, Harrington KJ, Nutting CM. Recovery of Salivary Function: Contralateral Parotid-sparing Intensity-modulated Radiotherapy versus Bilateral Superficial Lobe Parotid-sparing Intensity-modulated Radiotherapy. Clin Oncol (R Coll Radiol) 2016; 28:e69-e76. [PMID: 26994893 PMCID: PMC4979532 DOI: 10.1016/j.clon.2016.02.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Revised: 02/06/2016] [Accepted: 02/09/2016] [Indexed: 11/23/2022]
Abstract
AIMS To establish whether there is a difference in recovery of salivary function with bilateral superficial lobe parotid-sparing intensity-modulated radiotherapy (BSLPS-IMRT) versus contralateral parotid-sparing IMRT (CLPS-IMRT) in patients with locally advanced head and neck squamous cell cancers. MATERIALS AND METHODS A dosimetric analysis was carried out on data from two studies in which patients received BSLPS-IMRT (PARSPORT II) or CLPS-IMRT (PARSPORT). Acute (National Cancer Institute, Common Terminology Criteria for adverse events - NCI CTCAEv3.0) and late (Late Effects of Normal Tissue- subjective, objective, management analytical - LENTSOMA and Radiation Therapy Oncology Group) xerostomia scores were dichotomised: recovery (grade 0-1) versus no recovery (≥grade 2). Incidence of recovery of salivary function was compared between the two techniques and dose-response relationships were determined by fitting dose-response curves to the data using non-linear logistic regression analysis. RESULTS Seventy-one patients received BSLPS-IMRT and 35 received CLPS-IMRT. Patients received 65 Gy in 30 fractions to the primary site and involved nodal levels and 54 Gy in 30 fractions to elective nodal levels. There were significant differences in mean doses to contralateral parotid gland (29.4 Gy versus 24.9 Gy, P < 0.005) and superficial lobes (26.8 Gy versus 30.5 Gy, P = 0.02) for BSLPS and CLPS-IMRT, respectively. Lower risk of long-term ≥grade 2 subjective xerostomia (LENTSOMA) was reported with BSLPS-IMRT (odds ratio 0.50; 95% confidence interval 0.29-0.86; P = 0.012). The percentage of patients who reported recovery of parotid saliva flow at 1 year was higher with BSLPS-IMRT compared with CLPS-IMRT techniques (67.1% versus 52.8%), but the difference was not statistically significant (P = 0.12). For the whole parotid gland, the tolerance doses, D50, were 25.6 Gy (95% confidence interval 20.6-30.5), k = 2.7 (0.9-4.5) (CLPS-IMRT) and 28.9 Gy (26.1-31.9), k = 2.4 (1.4-3.4) (BSLPS-IMRT). For the superficial lobe, D50 were similar: BSLPS-IMRT 23.5 Gy (19.3-27.6), k = 1.9 (0.5-3.8); CLPS-IMRT 24.0 Gy (17.7-30.1), k = 2.1 (0.1-4.1). CONCLUSION BSLPS-IMRT reduces the risk of developing high-grade subjective xerostomia compared with CLPS-IMRT. The D50 of the superficial lobe may be a more reliable predictor of recovery of parotid function than the whole gland mean dose.
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Affiliation(s)
- A B Miah
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - S L Gulliford
- Joint Department of Physics, The Institute of Cancer Research, Surrey, UK
| | - J Morden
- The Institute of Cancer Research, Clinical Trials and Statistic Unit, London, UK
| | - K L Newbold
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - S A Bhide
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - S H Zaidi
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - E Hall
- The Institute of Cancer Research, Clinical Trials and Statistic Unit, London, UK
| | - K J Harrington
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | - C M Nutting
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK.
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21
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Dean JA, Wong KH, Gay H, Welsh LC, Jones AB, Schick U, Oh JH, Apte A, Newbold KL, Bhide SA, Harrington KJ, Deasy JO, Nutting CM, Gulliford SL. Functional Data Analysis Applied to Modeling of Severe Acute Mucositis and Dysphagia Resulting From Head and Neck Radiation Therapy. Int J Radiat Oncol Biol Phys 2016; 96:820-831. [PMID: 27788955 PMCID: PMC5653218 DOI: 10.1016/j.ijrobp.2016.08.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 07/29/2016] [Accepted: 08/12/2016] [Indexed: 11/05/2022]
Abstract
Purpose Current normal tissue complication probability modeling using logistic regression suffers from bias and high uncertainty in the presence of highly correlated radiation therapy (RT) dose data. This hinders robust estimates of dose-response associations and, hence, optimal normal tissue—sparing strategies from being elucidated. Using functional data analysis (FDA) to reduce the dimensionality of the dose data could overcome this limitation. Methods and Materials FDA was applied to modeling of severe acute mucositis and dysphagia resulting from head and neck RT. Functional partial least squares regression (FPLS) and functional principal component analysis were used for dimensionality reduction of the dose-volume histogram data. The reduced dose data were input into functional logistic regression models (functional partial least squares—logistic regression [FPLS-LR] and functional principal component—logistic regression [FPC-LR]) along with clinical data. This approach was compared with penalized logistic regression (PLR) in terms of predictive performance and the significance of treatment covariate—response associations, assessed using bootstrapping. Results The area under the receiver operating characteristic curve for the PLR, FPC-LR, and FPLS-LR models was 0.65, 0.69, and 0.67, respectively, for mucositis (internal validation) and 0.81, 0.83, and 0.83, respectively, for dysphagia (external validation). The calibration slopes/intercepts for the PLR, FPC-LR, and FPLS-LR models were 1.6/−0.67, 0.45/0.47, and 0.40/0.49, respectively, for mucositis (internal validation) and 2.5/−0.96, 0.79/−0.04, and 0.79/0.00, respectively, for dysphagia (external validation). The bootstrapped odds ratios indicated significant associations between RT dose and severe toxicity in the mucositis and dysphagia FDA models. Cisplatin was significantly associated with severe dysphagia in the FDA models. None of the covariates was significantly associated with severe toxicity in the PLR models. Dose levels greater than approximately 1.0 Gy/fraction were most strongly associated with severe acute mucositis and dysphagia in the FDA models. Conclusions FPLS and functional principal component analysis marginally improved predictive performance compared with PLR and provided robust dose-response associations. FDA is recommended for use in normal tissue complication probability modeling.
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Affiliation(s)
- Jamie A Dean
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK.
| | - Kee H Wong
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - Hiram Gay
- Department of Radiation Oncology, School of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Liam C Welsh
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - Ann-Britt Jones
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - Ulrike Schick
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - Jung Hun Oh
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Aditya Apte
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kate L Newbold
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK; Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | - Shreerang A Bhide
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK; Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | - Kevin J Harrington
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK; Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | - Joseph O Deasy
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Christopher M Nutting
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK; Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | - Sarah L Gulliford
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
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McQuaid D, Dunlop A, Nill S, Franzese C, Nutting CM, Harrington KJ, Newbold KL, Bhide SA. Evaluation of radiotherapy techniques for radical treatment of lateralised oropharyngeal cancers : Dosimetry and NTCP. Strahlenther Onkol 2016; 192:516-25. [PMID: 27295511 DOI: 10.1007/s00066-016-0980-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 04/12/2016] [Indexed: 12/22/2022]
Abstract
AIM The aim of this study was to investigate potential advantages and disadvantages of three-dimensional conformal radiotherapy (3DCRT), multiple fixed-field intensity-modulated radiotherapy (IMRT) and volumetric-modulated arc therapy (VMAT) in terms of dose to the planning target volume (PTV), organs at risk (OARs) and normal tissue complication probability (NTCP) for delivering ipsilateral radiotherapy. MATERIALS AND METHODS 3DCRT, IMRT and VMAT were compared in patients with well-lateralised primary tonsillar cancers who underwent primary radical ipsilateral radiotherapy. The following parameters were compared: conformity index (CI); homogeneity index (HI); dose-volume histograms (DVHs) of PTVs and OARs; NTCP, risk of radiation-induced cancer and dose accumulation during treatment. RESULTS IMRT and VMAT were superior to 3DCRT in terms of CI, HI and dose to the target volumes, as well as mandible and dose accumulation robustness. The techniques were equivalent in terms of dose and NTCP for the contralateral oral cavity, contralateral submandibular gland and mandible, when specific dose constraint objectives were used on the oral cavity volume. Although the volume of normal tissue exposed to low-dose radiation was significantly higher with IMRT and VMAT, the risk of radiation-induced secondary malignancy was dependant on the mathematical model used. CONCLUSION This study demonstrates the superiority of IMRT/VMAT techniques over 3DCRT in terms of dose homogeneity, conformity and consistent dose delivery to the PTV throughout the course of treatment in patients with lateralised oropharyngeal cancers. Dosimetry and NTCP calculations show that these techniques are equivalent to 3DCRT with regard to the risk of acute mucositis when specific dose constraint objectives were used on the contralateral oral cavity OAR.
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Affiliation(s)
- D McQuaid
- Head and Neck Unit, Royal Marsden Hospital, Downs road, SM2 5PT, Sutton, Surrey, UK
- Head and Neck Unit, Royal Marsden Hospital, SW3 6JJ, London, UK
- The Institute of Cancer Research, SW3 6JB, London, UK
- The Institute of Cancer Research, SM2 5NG, Sutton, UK
| | - A Dunlop
- Head and Neck Unit, Royal Marsden Hospital, Downs road, SM2 5PT, Sutton, Surrey, UK
- Head and Neck Unit, Royal Marsden Hospital, SW3 6JJ, London, UK
- The Institute of Cancer Research, SW3 6JB, London, UK
- The Institute of Cancer Research, SM2 5NG, Sutton, UK
| | - S Nill
- Head and Neck Unit, Royal Marsden Hospital, Downs road, SM2 5PT, Sutton, Surrey, UK
- Head and Neck Unit, Royal Marsden Hospital, SW3 6JJ, London, UK
- The Institute of Cancer Research, SW3 6JB, London, UK
- The Institute of Cancer Research, SM2 5NG, Sutton, UK
| | - C Franzese
- Head and Neck Unit, Royal Marsden Hospital, Downs road, SM2 5PT, Sutton, Surrey, UK
- Head and Neck Unit, Royal Marsden Hospital, SW3 6JJ, London, UK
| | - C M Nutting
- Head and Neck Unit, Royal Marsden Hospital, Downs road, SM2 5PT, Sutton, Surrey, UK
- Head and Neck Unit, Royal Marsden Hospital, SW3 6JJ, London, UK
- The Institute of Cancer Research, SW3 6JB, London, UK
- The Institute of Cancer Research, SM2 5NG, Sutton, UK
| | - K J Harrington
- Head and Neck Unit, Royal Marsden Hospital, Downs road, SM2 5PT, Sutton, Surrey, UK
- Head and Neck Unit, Royal Marsden Hospital, SW3 6JJ, London, UK
- The Institute of Cancer Research, SW3 6JB, London, UK
- The Institute of Cancer Research, SM2 5NG, Sutton, UK
| | - K L Newbold
- Head and Neck Unit, Royal Marsden Hospital, Downs road, SM2 5PT, Sutton, Surrey, UK
- Head and Neck Unit, Royal Marsden Hospital, SW3 6JJ, London, UK
- The Institute of Cancer Research, SW3 6JB, London, UK
- The Institute of Cancer Research, SM2 5NG, Sutton, UK
| | - S A Bhide
- Head and Neck Unit, Royal Marsden Hospital, Downs road, SM2 5PT, Sutton, Surrey, UK.
- Head and Neck Unit, Royal Marsden Hospital, SW3 6JJ, London, UK.
- The Institute of Cancer Research, SW3 6JB, London, UK.
- The Institute of Cancer Research, SM2 5NG, Sutton, UK.
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23
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Barker HE, Patel R, McLaughlin M, Schick U, Zaidi S, Nutting CM, Newbold KL, Bhide S, Harrington KJ. CHK1 Inhibition Radiosensitizes Head and Neck Cancers to Paclitaxel-Based Chemoradiotherapy. Mol Cancer Ther 2016; 15:2042-54. [PMID: 27422809 DOI: 10.1158/1535-7163.mct-15-0998] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 06/10/2016] [Indexed: 11/16/2022]
Abstract
Head and neck squamous cell carcinoma (HNSCC) is a leading cause of cancer-related deaths, with increasingly more cases arising due to high-risk human papillomavirus (HPV) infection. Cisplatin-based chemoradiotherapy is a standard-of-care for locally advanced head and neck cancer but is frequently ineffective. Research into enhancing radiation responses as a means of improving treatment outcomes represents a high priority. Here, we evaluated a CHK1 inhibitor (CCT244747) as a radiosensitiser and investigated whether a mechanistically rational triple combination of radiation/paclitaxel/CHK1 inhibitor delivered according to an optimized schedule would provide added benefit. CCT244747 abrogated radiation-induced G2 arrest in the p53-deficient HNSCC cell lines, HN4 and HN5, causing cells to enter mitosis with unrepaired DNA damage. The addition of paclitaxel further increased cell kill and significantly reduced tumor growth in an HN5 xenograft model. Importantly, a lower dose of paclitaxel could be used when CCT244747 was included, therefore potentially limiting toxicity. Triple therapy reduced the expression of several markers of radioresistance. Moreover, the more radioresistant HN5 cell line exhibited greater radiation-mediated CHK1 activation and was more sensitive to triple therapy than HN4 cells. We analyzed CHK1 expression in a panel of head and neck tumors and observed that primary tumors from HPV(+) patients, who went on to recur postradiotherapy, exhibited significantly stronger expression of total, and activated CHK1. CHK1 may serve as a biomarker for identifying tumors likely to recur and, therefore, patients who may benefit from concomitant treatment with a CHK1 inhibitor and paclitaxel during radiotherapy. Clinical translation of this strategy is under development. Mol Cancer Ther; 15(9); 2042-54. ©2016 AACR.
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Affiliation(s)
- Holly E Barker
- Targeted Therapy Team, Division of Cancer Biology, The Institute of Cancer Research, Chester Beatty Laboratories, London, United Kingdom.
| | - Radhika Patel
- Targeted Therapy Team, Division of Cancer Biology, The Institute of Cancer Research, Chester Beatty Laboratories, London, United Kingdom
| | - Martin McLaughlin
- Targeted Therapy Team, Division of Cancer Biology, The Institute of Cancer Research, Chester Beatty Laboratories, London, United Kingdom
| | - Ulrike Schick
- Targeted Therapy Team, Division of Cancer Biology, The Institute of Cancer Research, Chester Beatty Laboratories, London, United Kingdom. Radiation Oncology Unit, University Hospital, Brest, France
| | - Shane Zaidi
- Targeted Therapy Team, Division of Cancer Biology, The Institute of Cancer Research, Chester Beatty Laboratories, London, United Kingdom. Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London and Surrey, United Kingdom
| | - Christopher M Nutting
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London and Surrey, United Kingdom
| | - Katie L Newbold
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London and Surrey, United Kingdom
| | - Shreerang Bhide
- Targeted Therapy Team, Division of Cancer Biology, The Institute of Cancer Research, Chester Beatty Laboratories, London, United Kingdom. Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London and Surrey, United Kingdom
| | - Kevin J Harrington
- Targeted Therapy Team, Division of Cancer Biology, The Institute of Cancer Research, Chester Beatty Laboratories, London, United Kingdom. Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London and Surrey, United Kingdom
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Gujral DM, Cheung WK, Shah BN, Chahal NS, Bhattacharyya S, Hooper J, Senior R, Tang MX, Harrington KJ, Nutting CM. Contrast enhancement of carotid adventitial vasa vasorum as a biomarker of radiation-induced atherosclerosis. Radiother Oncol 2016; 120:63-8. [PMID: 27370203 DOI: 10.1016/j.radonc.2016.06.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2015] [Revised: 06/15/2016] [Accepted: 06/18/2016] [Indexed: 11/25/2022]
Abstract
PURPOSE Abnormal proliferation of adventitial vasa vasorum (vv) occurs early at sites of atherosclerosis and is thought to be an early biomarker of vascular damage. Contrast-enhanced ultrasound (CEUS) can detect this process. Its usefulness in irradiated arteries as a measure of accelerated atherosclerosis is unknown. This study investigates contrast intensity in carotid adventitia as an early marker of radiation-induced damage in head and neck cancer (HNC) patients. MATERIALS/METHODS Patients with HNC treated with a wedged-pair and matched neck technique or hemi-neck radiotherapy (RT) (unirradiated side as control) at least 2years previously were included. Patients had been prescribed a dose of at least 50Gy to the neck. CEUS was performed on both carotid arteries and a region of interest was selected in the adventitia of the far wall of both left and right distal common carotid arteries. Novel quantification software was used to compare the average intensity per pixel between irradiated and unirradiated arteries. RESULTS 48 patients (34 males) with median age of 59.2years (interquartile range (IQR) 49.2-64.2) were included. The mean maximum point dose to the irradiated artery was 61.2Gy (IQR 52.6-61.8) and 1.1Gy (IQR 1.0-1.8Gy) to the unirradiated side. The median interval from RT was 59.4months (IQR 41-88.7). There was a significant difference in the mean (SD) contrast intensity per pixel on the irradiated side (1.1 (0.4)) versus 0.96 (0.34) on the unirradiated side (p=0.01). After attenuation correction, the difference in mean contrast intensity per pixel was still significant (1.4 (0.58) versus 1.2 (0.47) (p=0.02). Previous surgery or chemotherapy had no effect on the difference in contrast intensity between the 2 sides of the neck. Mean intensity per pixel did not correlate to traditional risk prediction models (carotid intima-medial thickness, QSTROKE score). CONCLUSIONS Proliferation of vv is demonstrated by increased contrast intensity in irradiated carotid arteries. This may be a useful, independent biomarker of radiation-induced carotid atherosclerosis when used as a tool to quantify neovascularization.
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Affiliation(s)
| | | | - Benoy N Shah
- Department of Echocardiography, Royal Brompton Hospital, London, UK
| | - Navtej S Chahal
- Department of Echocardiography, Royal Brompton Hospital, London, UK
| | | | - James Hooper
- Department of Biochemistry, Royal Brompton Hospital, London, UK
| | - Roxy Senior
- Department of Echocardiography, Royal Brompton Hospital, London, UK
| | - Meng-Xing Tang
- Department of Bioengineering, Imperial College, London, UK
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Dean JA, Wong KH, Welsh LC, Jones AB, Schick U, Newbold KL, Bhide SA, Harrington KJ, Nutting CM, Gulliford SL. Normal tissue complication probability (NTCP) modelling using spatial dose metrics and machine learning methods for severe acute oral mucositis resulting from head and neck radiotherapy. Radiother Oncol 2016; 120:21-7. [PMID: 27240717 PMCID: PMC5021201 DOI: 10.1016/j.radonc.2016.05.015] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 04/18/2016] [Accepted: 05/12/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND PURPOSE Severe acute mucositis commonly results from head and neck (chemo)radiotherapy. A predictive model of mucositis could guide clinical decision-making and inform treatment planning. We aimed to generate such a model using spatial dose metrics and machine learning. MATERIALS AND METHODS Predictive models of severe acute mucositis were generated using radiotherapy dose (dose-volume and spatial dose metrics) and clinical data. Penalised logistic regression, support vector classification and random forest classification (RFC) models were generated and compared. Internal validation was performed (with 100-iteration cross-validation), using multiple metrics, including area under the receiver operating characteristic curve (AUC) and calibration slope, to assess performance. Associations between covariates and severe mucositis were explored using the models. RESULTS The dose-volume-based models (standard) performed equally to those incorporating spatial information. Discrimination was similar between models, but the RFCstandard had the best calibration. The mean AUC and calibration slope for this model were 0.71 (s.d.=0.09) and 3.9 (s.d.=2.2), respectively. The volumes of oral cavity receiving intermediate and high doses were associated with severe mucositis. CONCLUSIONS The RFCstandard model performance is modest-to-good, but should be improved, and requires external validation. Reducing the volumes of oral cavity receiving intermediate and high doses may reduce mucositis incidence.
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Affiliation(s)
- Jamie A Dean
- Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK.
| | - Kee H Wong
- The Royal Marsden NHS Foundation Trust, London, UK
| | - Liam C Welsh
- The Royal Marsden NHS Foundation Trust, London, UK
| | | | | | - Kate L Newbold
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | - Shreerang A Bhide
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | - Kevin J Harrington
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | - Christopher M Nutting
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | - Sarah L Gulliford
- Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
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Panek R, Welsh L, Dunlop A, Wong KH, Riddell AM, Koh DM, Schmidt MA, Doran S, Mcquaid D, Hopkinson G, Richardson C, Nutting CM, Bhide SA, Harrington KJ, Robinson SP, Newbold KL, Leach MO. Repeatability and sensitivity of T2* measurements in patients with head and neck squamous cell carcinoma at 3T. J Magn Reson Imaging 2016; 44:72-80. [PMID: 26800280 PMCID: PMC4915498 DOI: 10.1002/jmri.25134] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 12/02/2015] [Indexed: 12/17/2022] Open
Abstract
PURPOSE To determine whether quantitation of T2* is sufficiently repeatable and sensitive to detect clinically relevant oxygenation levels in head and neck squamous cell carcinoma (HNSCC) at 3T. MATERIALS AND METHODS Ten patients with newly diagnosed locally advanced HNSCC underwent two magnetic resonance imaging (MRI) scans between 24 and 168 hours apart prior to chemoradiotherapy treatment. A multiple gradient echo sequence was used to calculate T2* maps. A quadratic function was used to model the blood transverse relaxation rate as a function of blood oxygenation. A set of published coefficients measured at 3T were incorporated to account for tissue hematocrit levels and used to plot the dependence of fractional blood oxygenation (Y) on T2* values, together with the corresponding repeatability range. Repeatability of T2* using Bland-Altman analysis, and calculation of limits of agreement (LoA), was used to assess the sensitivity, defined as the minimum difference in fractional blood oxygenation that can be confidently detected. RESULTS T2* LoA for 22 outlined tumor volumes were 13%. The T2* dependence of fractional blood oxygenation increases monotonically, resulting in increasing sensitivity of the method with increasing blood oxygenation. For fractional blood oxygenation values above 0.11, changes in T2* were sufficient to detect differences in blood oxygenation greater than 10% (Δ T2* > LoA for ΔY > 0.1). CONCLUSION Quantitation of T2* at 3T can detect clinically relevant changes in tumor oxygenation within a wide range of blood volumes and oxygen tensions, including levels reported in HNSCC. J. Magn. Reson. Imaging 2016;44:72-80.
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Affiliation(s)
- Rafal Panek
- CR-UK Cancer Imaging Centre, London, UK
- Institute of Cancer Research, London, UK
- Royal Marsden NHS Trust, London, UK
| | - Liam Welsh
- Institute of Cancer Research, London, UK
- Royal Marsden NHS Trust, London, UK
| | - Alex Dunlop
- Institute of Cancer Research, London, UK
- Royal Marsden NHS Trust, London, UK
| | - Kee H Wong
- Institute of Cancer Research, London, UK
- Royal Marsden NHS Trust, London, UK
| | - Angela M Riddell
- CR-UK Cancer Imaging Centre, London, UK
- Institute of Cancer Research, London, UK
- Royal Marsden NHS Trust, London, UK
| | - Dow-Mu Koh
- CR-UK Cancer Imaging Centre, London, UK
- Institute of Cancer Research, London, UK
- Royal Marsden NHS Trust, London, UK
| | - Maria A Schmidt
- CR-UK Cancer Imaging Centre, London, UK
- Institute of Cancer Research, London, UK
- Royal Marsden NHS Trust, London, UK
| | - Simon Doran
- CR-UK Cancer Imaging Centre, London, UK
- Institute of Cancer Research, London, UK
- Royal Marsden NHS Trust, London, UK
| | - Dualta Mcquaid
- Institute of Cancer Research, London, UK
- Royal Marsden NHS Trust, London, UK
| | | | | | | | - Shreerang A Bhide
- Institute of Cancer Research, London, UK
- Royal Marsden NHS Trust, London, UK
| | - Kevin J Harrington
- Institute of Cancer Research, London, UK
- Royal Marsden NHS Trust, London, UK
| | - Simon P Robinson
- CR-UK Cancer Imaging Centre, London, UK
- Institute of Cancer Research, London, UK
| | - Kate L Newbold
- Institute of Cancer Research, London, UK
- Royal Marsden NHS Trust, London, UK
| | - Martin O Leach
- CR-UK Cancer Imaging Centre, London, UK
- Institute of Cancer Research, London, UK
- Royal Marsden NHS Trust, London, UK
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Gujral DM, Shah BN, Chahal NS, Bhattacharyya S, Senior R, Harrington KJ, Nutting CM. Do traditional risk stratification models for cerebrovascular events apply in irradiated head and neck cancer patients? QJM 2016; 109:383-9. [PMID: 26109594 DOI: 10.1093/qjmed/hcv120] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2015] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Primary radical radiotherapy (RT) for head and neck cancer (HNC) often results in significant radiation dose to the carotid arteries. AIM We assessed whether HNC patients are at increased risk of a cerebrovascular event primarily due to RT or other risk factors for atherosclerosis by (i) risk-stratifying patients according to validated QRISK-2 and QSTROKE scores and (ii) comparing the prevalence of carotid artery stenosis (CAS) in irradiated and unirradiated carotid arteries. DESIGN HNC patients treated with an RT dose >50 Gy to one side of the neck ≥2 years previously were included. METHODS QRISK-2 (2014) and Q-STROKE (2014) scores were calculated. We compared the prevalence of CAS in segments of the common carotid artery on the irradiated and unirradiated sides of the neck. RESULTS Fifty patients (median age of 58 years (interquartile range (IQR) 50-62)) were included. The median QRISK-2 score was 10% (IQR 4.4-15%) and the median QSTROKE score was 3.4% (IQR 1.4-5.3%). For both scores, no patient was classified as high risk. Thirty-eight patients (76%) had CAS in one or both arteries. There was a significant difference in the number of irradiated arteries with stenosis (N = 37) compared with unirradiated arteries (N = 16) (P < 0.0001). There were more plaques on the irradiated artery compared with the unirradiated side - 64/87 (73.6%) versus 23/87 (26.4%), respectively (P < 0.001). CONCLUSIONS Traditional vascular risk factors do not play a role in radiation-induced carotid atherosclerosis. Clinicians should be aware that traditional risk prediction models may under-estimate stroke risk in these patients.
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Affiliation(s)
- D M Gujral
- From the Head and Neck Unit, Department of Radiotherapy, The Royal Marsden Hospital, 203 Fulham Road, London SW3 6JJ, UK and
| | - B N Shah
- Department of Echocardiography, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
| | - N S Chahal
- Department of Echocardiography, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
| | - S Bhattacharyya
- Department of Echocardiography, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
| | - R Senior
- Department of Echocardiography, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
| | - K J Harrington
- From the Head and Neck Unit, Department of Radiotherapy, The Royal Marsden Hospital, 203 Fulham Road, London SW3 6JJ, UK and
| | - C M Nutting
- From the Head and Neck Unit, Department of Radiotherapy, The Royal Marsden Hospital, 203 Fulham Road, London SW3 6JJ, UK and
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28
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Dean JA, Welsh LC, McQuaid D, Wong KH, Aleksic A, Dunne E, Islam MR, Patel A, Patel P, Petkar I, Phillips I, Sham J, Newbold KL, Bhide SA, Harrington KJ, Gulliford SL, Nutting CM. Assessment of fully-automated atlas-based segmentation of novel oral mucosal surface organ-at-risk. Radiother Oncol 2016; 119:166-71. [PMID: 26970676 DOI: 10.1016/j.radonc.2016.02.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 02/05/2016] [Accepted: 02/09/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE Current oral mucositis normal tissue complication probability models, based on the dose distribution to the oral cavity volume, have suboptimal predictive power. Improving the delineation of the oral mucosa is likely to improve these models, but is resource intensive. We developed and evaluated fully-automated atlas-based segmentation (ABS) of a novel delineation technique for the oral mucosal surfaces. MATERIAL AND METHODS An atlas of mucosal surface contours (MSC) consisting of 46 patients was developed. It was applied to an independent test cohort of 10 patients for whom manual segmentation of MSC structures, by three different clinicians, and conventional outlining of oral cavity contours (OCC), by an additional clinician, were also performed. Geometric comparisons were made using the dice similarity coefficient (DSC), validation index (VI) and Hausdorff distance (HD). Dosimetric comparisons were carried out using dose-volume histograms. RESULTS The median difference, in the DSC and HD, between automated-manual comparisons and manual-manual comparisons were small and non-significant (-0.024; p=0.33 and -0.5; p=0.88, respectively). The median VI was 0.086. The maximum normalised volume difference between automated and manual MSC structures across all of the dose levels, averaged over the test cohort, was 8%. This difference reached approximately 28% when comparing automated MSC and OCC structures. CONCLUSIONS Fully-automated ABS of MSC is suitable for use in radiotherapy dose-response modelling.
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Affiliation(s)
- Jamie A Dean
- Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK.
| | - Liam C Welsh
- The Royal Marsden NHS Foundation Trust, London, UK
| | - Dualta McQuaid
- Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - Kee H Wong
- The Royal Marsden NHS Foundation Trust, London, UK
| | | | - Emma Dunne
- The Royal Marsden NHS Foundation Trust, London, UK
| | | | | | | | - Imran Petkar
- The Royal Marsden NHS Foundation Trust, London, UK
| | | | - Jackie Sham
- The Royal Marsden NHS Foundation Trust, London, UK
| | - Kate L Newbold
- The Royal Marsden NHS Foundation Trust, London, UK; Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | - Shreerang A Bhide
- The Royal Marsden NHS Foundation Trust, London, UK; Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | - Kevin J Harrington
- The Royal Marsden NHS Foundation Trust, London, UK; Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | - Sarah L Gulliford
- Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - Christopher M Nutting
- The Royal Marsden NHS Foundation Trust, London, UK; Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
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29
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Miah AB, Bhide SA, Del Rosario L, Matthews J, Nicol R, Tanay MA, Gupta S, Zaidi SH, Newbold KL, Harrington KJ, Nutting CM. Induction Chemotherapy Followed by Chemo-intensity-modulated Radiotherapy for Locally Advanced Nasopharyngeal Cancer. Clin Oncol (R Coll Radiol) 2016; 28:e61-7. [PMID: 26876458 DOI: 10.1016/j.clon.2016.01.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Revised: 12/01/2015] [Accepted: 12/30/2015] [Indexed: 11/16/2022]
Abstract
AIMS To determine the toxicity and tumour control rates after chemo-intensity-modulated radiotherapy (chemo-IMRT) for locally advanced nasopharyngeal cancers (LA-NPC). MATERIALS AND METHODS Patients with LA-NPC were enrolled in a trial to receive induction chemotherapy followed by parotid-sparing chemo-IMRT. The primary site and involved nodal levels received 65 Gy in 30 fractions and at risk nodal levels received 54 Gy in 30 fractions. Incidence of ≥grade 2 subjective xerostomia was the primary end point. Secondary end points included incidences of acute and late toxicities and survival outcomes. RESULTS Forty-two patients with American Joint Committee on Cancer stages II (12%), III (26%) and IV (62%) (World Health Organization subtype: I [5%]; II [40%]; III [55%]) completed treatment between January 2006 and April 2010 with a median follow-up of 32 months. Incidences of ≥grade 2 acute toxicities were: dysphagia 83%; xerostomia 76%; mucositis 97%; pain 76%; fatigue 99% and ototoxicity 12%. At 12 months, ≥grade 2 subjective xerostomia was observed in 31%, ototoxicitiy in 13% and dysphagia in 4%. Two year locoregional control was 86.2% (95% confidence interval: 70.0-94.0) with 2 year progression-free survival at 78.4% (61.4-88.6) and 2 year overall survival at 85.9% (69.3-93.9). CONCLUSIONS Chemo-IMRT for LA-NPC is feasible with good survival outcomes. At 1 year, 31% experience ≥grade 2 subjective xerostomia.
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Affiliation(s)
- A B Miah
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | - S A Bhide
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | - L Del Rosario
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - J Matthews
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - R Nicol
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - M A Tanay
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - S Gupta
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - S H Zaidi
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - K L Newbold
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | - K J Harrington
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | - C M Nutting
- The Institute of Cancer Research, London, UK.
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Gujral DM, Shah BN, Bhattacharyya S, Senior R, Harrington KJ, Nutting CM. Contrast-enhanced ultrasound to assess plaque neovascularization in irradiated carotid arteries. Int J Cardiol 2016; 202:3-4. [PMID: 26368025 DOI: 10.1016/j.ijcard.2015.08.176] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 08/21/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Dorothy M Gujral
- Head and Neck Unit, The Royal Marsden Hospital, 203 Fulham Road, London SW3 6JJ, UK
| | - Benoy N Shah
- Department of Echocardiography, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
| | - Sanjeev Bhattacharyya
- Department of Echocardiography, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
| | - Roxy Senior
- Department of Echocardiography, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
| | - Kevin J Harrington
- Head and Neck Unit, The Royal Marsden Hospital, 203 Fulham Road, London SW3 6JJ, UK
| | - Christopher M Nutting
- Head and Neck Unit, The Royal Marsden Hospital, 203 Fulham Road, London SW3 6JJ, UK.
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31
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Roe JWG, Carding PN, Drinnan MJ, Harrington KJ, Nutting CM. Swallowing performance and tube feeding status in patients treated with parotid-sparing intensity-modulated radiotherapy for head and neck cancer. Head Neck 2015; 38 Suppl 1:E1436-44. [PMID: 26566740 DOI: 10.1002/hed.24255] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 06/24/2015] [Accepted: 08/25/2015] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The purpose of this prospective study was to evaluate the swallowing performance of patients with head and neck cancer treated with parotid-sparing intensity-modulated radiotherapy (IMRT). METHODS Sixty-two patients were recruited. Data were collected before and up to 12 months after treatment. Measures included the Performance Status Scale for head and neck cancer (PSS-HN Normalcy of Diet and Eating in Public subscales), tube feeding status, and 100 mL water swallow test (WST) volume and capacity scores. RESULTS There was a significant reduction in PSS-HN and WST scores from baseline to 3 months (p < .001). Significant improvements were observed up to 12 months on the PSS-HN. Swallowing volume and capacity scores recovered but did not reach statistical significance. Tube feeding was not required in 47% of the patients. CONCLUSION IMRT significantly impacts on swallowing performance, although there is a trend for improvement up to 12 months after treatment. Our data support a case-by-case approach to tube feeding. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1436-E1444, 2016.
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Affiliation(s)
- Justin W G Roe
- Department of Speech and Language Therapy, The Royal Marsden NHS Foundation Trust, London, UK.,The Institute of Cancer Research, London, UK
| | - Paul N Carding
- Speech Pathology, School of Allied Health, Australian National Catholic University, Brisbane Campus, Queensland, Australia
| | - Michael J Drinnan
- Department of Medical Physics, Freeman Hospital, Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Institute of Cellular Medicine, University of Newcastle upon Tyne, UK
| | - Kevin J Harrington
- The Institute of Cancer Research, London, UK.,Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - Christopher M Nutting
- The Institute of Cancer Research, London, UK.,Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
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Borri M, Schmidt MA, Powell C, Koh DM, Riddell AM, Partridge M, Bhide SA, Nutting CM, Harrington KJ, Newbold KL, Leach MO. Characterizing Heterogeneity within Head and Neck Lesions Using Cluster Analysis of Multi-Parametric MRI Data. PLoS One 2015; 10:e0138545. [PMID: 26398888 PMCID: PMC4580650 DOI: 10.1371/journal.pone.0138545] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 09/01/2015] [Indexed: 01/20/2023] Open
Abstract
PURPOSE To describe a methodology, based on cluster analysis, to partition multi-parametric functional imaging data into groups (or clusters) of similar functional characteristics, with the aim of characterizing functional heterogeneity within head and neck tumour volumes. To evaluate the performance of the proposed approach on a set of longitudinal MRI data, analysing the evolution of the obtained sub-sets with treatment. MATERIAL AND METHODS The cluster analysis workflow was applied to a combination of dynamic contrast-enhanced and diffusion-weighted imaging MRI data from a cohort of squamous cell carcinoma of the head and neck patients. Cumulative distributions of voxels, containing pre and post-treatment data and including both primary tumours and lymph nodes, were partitioned into k clusters (k = 2, 3 or 4). Principal component analysis and cluster validation were employed to investigate data composition and to independently determine the optimal number of clusters. The evolution of the resulting sub-regions with induction chemotherapy treatment was assessed relative to the number of clusters. RESULTS The clustering algorithm was able to separate clusters which significantly reduced in voxel number following induction chemotherapy from clusters with a non-significant reduction. Partitioning with the optimal number of clusters (k = 4), determined with cluster validation, produced the best separation between reducing and non-reducing clusters. CONCLUSION The proposed methodology was able to identify tumour sub-regions with distinct functional properties, independently separating clusters which were affected differently by treatment. This work demonstrates that unsupervised cluster analysis, with no prior knowledge of the data, can be employed to provide a multi-parametric characterization of functional heterogeneity within tumour volumes.
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Affiliation(s)
- Marco Borri
- CR-UK Cancer Imaging Centre, The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, London, United Kingdom
| | - Maria A. Schmidt
- CR-UK Cancer Imaging Centre, The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, London, United Kingdom
| | - Ceri Powell
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Dow-Mu Koh
- CR-UK Cancer Imaging Centre, The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, London, United Kingdom
- Radiology Department, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Angela M. Riddell
- Radiology Department, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Mike Partridge
- CRUK/MRC Oxford Institute for Radiation Oncology, University of Oxford, Oxford, United Kingdom
| | - Shreerang A. Bhide
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | | | - Kevin J. Harrington
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Katie L. Newbold
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Martin O. Leach
- CR-UK Cancer Imaging Centre, The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, London, United Kingdom
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Evans CM, Burnet NG, Hall E, Huddart RA, Nutting CM, Coles CE. The Radiotherapy Clinical Trial Research Landscape in the UK Between 2004 and 2013: A Cross-sectional Analysis. Clin Oncol (R Coll Radiol) 2015; 27:491-4. [PMID: 26051438 DOI: 10.1016/j.clon.2015.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 05/05/2015] [Accepted: 05/13/2015] [Indexed: 11/27/2022]
Affiliation(s)
- C M Evans
- Oncology Centre, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
| | - N G Burnet
- University of Cambridge Department of Oncology, Cambridge Biomedical Campus, Addenbrooke's Hospital, Cambridge, UK
| | - E Hall
- Clinical Trials and Statistics Unit at the Institute of Cancer Research, London, UK
| | - R A Huddart
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | - C M Nutting
- The Royal Marsden NHS Foundation Trust, London, UK
| | - C E Coles
- Oncology Centre, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Cheung WK, Gujral DM, Shah BN, Chahal NS, Bhattacharyya S, Cosgrove DO, Eckersley RJ, Harrington KJ, Senior R, Nutting CM, Tang MX. Attenuation Correction and Normalisation for Quantification of Contrast Enhancement in Ultrasound Images of Carotid Arteries. Ultrasound Med Biol 2015; 41:1876-1883. [PMID: 25843515 DOI: 10.1016/j.ultrasmedbio.2015.02.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Revised: 12/15/2014] [Accepted: 02/21/2015] [Indexed: 06/04/2023]
Abstract
An automated attenuation correction and normalisation algorithm was developed to improve the quantification of contrast enhancement in ultrasound images of carotid arteries. The algorithm first corrects attenuation artefact and normalises intensity within the contrast agent-filled lumen and then extends the correction and normalisation to regions beyond the lumen. The algorithm was first validated on phantoms consisting of contrast agent-filled vessels embedded in tissue-mimicking materials of known attenuation. It was subsequently applied to in vivo contrast-enhanced ultrasound (CEUS) images of human carotid arteries. Both in vitro and in vivo results indicated significant reduction in the shadowing artefact and improved homogeneity within the carotid lumens after the correction. The error in quantification of microbubble contrast enhancement caused by attenuation on phantoms was reduced from 55% to 5% on average. In conclusion, the proposed method exhibited great potential in reducing attenuation artefact and improving quantification in contrast-enhanced ultrasound of carotid arteries.
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Affiliation(s)
| | | | - Benoy N Shah
- Biomedical Research Unit, NHLI, Imperial College, London, UK
| | - Navtej S Chahal
- Biomedical Research Unit, NHLI, Imperial College, London, UK
| | | | | | | | | | - Roxy Senior
- Biomedical Research Unit, NHLI, Imperial College, London, UK
| | | | - Meng-Xing Tang
- Department of Bioengineering, Imperial College London, London, UK.
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Dwivedi RC, St Rose S, Chisholm EJ, Clarke PM, Kerawala CJ, Nutting CM, Rhys-Evans PH, Kazi R, Harrington KJ. Acoustic parameters of speech: Lack of correlation with perceptual and questionnaire-based speech evaluation in patients with oral and oropharyngeal cancer treated with primary surgery. Head Neck 2015; 38:670-6. [PMID: 25524696 DOI: 10.1002/hed.23956] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2014] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Acoustic evaluation of speech is the least explored method of speech evaluation in patients with oral cavity and oropharyngeal cancer. The purpose of this study was to explore acoustic parameters of speech and their correlation with questionnaire evaluation and perceptual evaluation in patients with oral cavity and oropharyngeal cancer. METHODS One hundred seventeen subjects (65 consecutive patients with oral cavity and oropharyngeal cancer and 52 controls) participated in this study. Formant frequencies (by Linear Predictive Coding), Speech Handicap Index, and London Speech Evaluation scale were used for acoustic evaluation, questionnaire evaluation, and perceptual evaluation, respectively. RESULTS Men showed significant elevation in second formant (F2) values for patients with oral cavity cancer and those who underwent surgery alone. Female patients with early T classification cancers and those who underwent surgery and chemoradiation showed significant reduction in the mean F2 values. Importantly, however, acoustic evaluation parameters did not correlate with either perceptual evaluation or questionnaire evaluation parameters, although there was moderate correlation between questionnaire evaluation and perceptual evaluation speech parameters. CONCLUSION Acoustic evaluation modalities have no clear role in the management of patients with oral cavity and oropharyngeal cancer.
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Affiliation(s)
- Raghav C Dwivedi
- Head and Neck Unit, Royal Marsden Hospital, London, United Kingdom.,The Institute of Cancer Research, London, United Kingdom
| | - Suzanne St Rose
- Research, Data and Statistical Unit, Royal Marsden Hospital, London, United Kingdom
| | | | - Peter M Clarke
- Head and Neck Unit, Royal Marsden Hospital, London, United Kingdom
| | - Cyrus J Kerawala
- Head and Neck Unit, Royal Marsden Hospital, London, United Kingdom
| | - Christopher M Nutting
- Head and Neck Unit, Royal Marsden Hospital, London, United Kingdom.,The Institute of Cancer Research, London, United Kingdom
| | - Peter H Rhys-Evans
- Head and Neck Unit, Royal Marsden Hospital, London, United Kingdom.,The Institute of Cancer Research, London, United Kingdom
| | - Rehan Kazi
- Head and Neck Unit, Royal Marsden Hospital, London, United Kingdom.,The Institute of Cancer Research, London, United Kingdom
| | - Kevin J Harrington
- Head and Neck Unit, Royal Marsden Hospital, London, United Kingdom.,The Institute of Cancer Research, London, United Kingdom
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36
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Gujral DM, Shah BN, Chahal NS, Bhattacharyya S, Senior R, Harrington KJ, Nutting CM. Arterial Stiffness as a Biomarker of Radiation-Induced Carotid Atherosclerosis. Angiology 2015; 67:266-71. [PMID: 26045515 DOI: 10.1177/0003319715589520] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Arterial stiffness is thought to be a precursor to atherosclerosis. Conventional arterial stiffness parameters as potential biomarkers of radiation-induced damage were investigated. Patients with head and neck cancer treated with radiotherapy ≥2 years previously to one side of the neck were included. The unirradiated side was the internal control. Beta stiffness index (B) and elastic modulus (Ep) were used to assess arterial stiffness and were measured in proximal, mid, and distal common carotid artery (CCA) and compared with the corresponding unirradiated segments. Fifty patients (68% male; median age 58 years; interquartile range 50-62) were included. Mean ± standard deviation maximum doses to irradiated and unirradiated arteries were 53 ± 13 and 1.9 ± 3.7 Gy, respectively. Differences in B were not significant. Significant differences in Ep were demonstrated-proximal CCA: 1301 ± 1223 versus 801 ± 492 (P < .0001), mid CCA: 1064 ± 818 versus 935.5 ± 793 (P < .0001), and distal CCA: 1267 ± 1084 versus 775.3 ± 551.9 (P < .0001). Surgery had no impact on arterial stiffness. Arterial stiffness is increased in irradiated arteries, in keeping with radiation-induced damage. Prospective data may show an association between arterial stiffness and atherosclerosis in this setting.
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Affiliation(s)
- Dorothy M Gujral
- Head and Neck Unit, The Royal Marsden Hospital, London, United Kingdom
| | - Benoy N Shah
- Department of Echocardiography, Royal Brompton Hospital, London, United Kingdom
| | - Navtej S Chahal
- Department of Echocardiography, Royal Brompton Hospital, London, United Kingdom
| | | | - Roxy Senior
- Department of Echocardiography, Royal Brompton Hospital, London, United Kingdom
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Dean JA, Welsh LC, Gulliford SL, Harrington KJ, Nutting CM. A novel method for delineation of oral mucosa for radiotherapy dose-response studies. Radiother Oncol 2015; 115:63-6. [PMID: 25779721 PMCID: PMC4641317 DOI: 10.1016/j.radonc.2015.02.020] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Revised: 02/02/2015] [Accepted: 02/05/2015] [Indexed: 11/27/2022]
Abstract
There is currently no standard method for delineating the oral mucosa and most attempts are oversimplified. A new method to obtain anatomically accurate contours of the oral mucosa surfaces was developed and applied to 11 patients. This is expected to represent an opportunity for improved toxicity modelling of oral mucositis.
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Affiliation(s)
- Jamie A Dean
- Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK.
| | - Liam C Welsh
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - Sarah L Gulliford
- Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
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Roe JWG, Drinnan MJ, Carding PN, Harrington KJ, Nutting CM. Patient-reported outcomes following parotid-sparing intensity-modulated radiotherapy for head and neck cancer. How important is dysphagia? Oral Oncol 2014; 50:1182-7. [PMID: 25448227 DOI: 10.1016/j.oraloncology.2014.09.009] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 09/15/2014] [Accepted: 09/17/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Swallowing can be significantly affected during and following radiotherapy for head and neck cancer (HNC). The purpose of this study was to understand: (1) the trajectory of swallowing recovery following parotid-sparing intensity-modulated radiotherapy (IMRT) and (2) overall physical and social-emotional wellbeing and how patients prioritise swallowing following treatment. MATERIALS AND METHODS Sixty-one HNC patients completed questionnaires as part of a prospective study exploring patient-reported swallowing outcomes following parotid-sparing IMRT. Participants were asked to complete the M.D. Anderson Dysphagia Inventory (MDADI) and University of Washington Quality of Life Questionnaire (UW-QoL) v.04 before treatment and 3, 6 and 12months after treatment. Given the rise in human papilloma virus (HPV) and associated oropharyngeal cancers, we completed a sub analysis of the data in those participants. RESULTS There was a significant reduction in the MDADI composite scores 3months after completion of treatment. Improvements were observed by 12months, however, scores did not recover to baseline. The recovery in physical function was limited in comparison to social-emotional recovery at 12months. When oropharyngeal cancer scores were analysed, there was not a substantial difference to the whole group results. There was a shift in priorities following treatment. Swallowing was highlighted as a concern by 44% of HNC patients up to 12months after treatment with swallowing-related factors (saliva, taste and chewing) rated highly. CONCLUSIONS Patient reported swallowing outcomes were significantly affected from baseline to all follow-up time points and remained a priority concern at 12months following treatment. Overall social-emotional functioning does improve, suggesting that patients have the potential to adapt to their "new normal" following IMRT for HNC.
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Affiliation(s)
- Justin W G Roe
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, Fulham Road, London SW3 6JJ, United Kingdom; The Institute of Cancer Research, 123 Old Brompton Road, London SW7 3RP, United Kingdom.
| | - Michael J Drinnan
- Institute of Cellular Medicine, University of Newcastle upon Tyne, NE1 7RU, United Kingdom.
| | - Paul N Carding
- School of Allied and Public Health, Australian Catholic University, Brisbane Campus, 1100 Nudgee Road, Banyo, Queensland, 4014, Australia.
| | - Kevin J Harrington
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, Fulham Road, London SW3 6JJ, United Kingdom; The Institute of Cancer Research, 123 Old Brompton Road, London SW7 3RP, United Kingdom.
| | - Christopher M Nutting
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, Fulham Road, London SW3 6JJ, United Kingdom; The Institute of Cancer Research, 123 Old Brompton Road, London SW7 3RP, United Kingdom.
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Lynch J, Lal P, Schick U, Nutting CM, Newbold K, Harrington K, Bhide S. Multiple cervical lymph node involvement and extra-capsular extension predict for contralateral nodal recurrence after ipsilateral radiotherapy for squamous cell carcinoma of the tonsil. Oral Oncol 2014; 50:901-6. [DOI: 10.1016/j.oraloncology.2014.06.019] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 06/24/2014] [Accepted: 06/25/2014] [Indexed: 12/20/2022]
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Brose MS, Nutting CM, Jarzab B, Elisei R, Siena S, Bastholt L, de la Fouchardiere C, Pacini F, Paschke R, Shong YK, Sherman SI, Smit JWA, Chung J, Kappeler C, Peña C, Molnár I, Schlumberger MJ. Sorafenib in radioactive iodine-refractory, locally advanced or metastatic differentiated thyroid cancer: a randomised, double-blind, phase 3 trial. Lancet 2014; 384:319-28. [PMID: 24768112 PMCID: PMC4366116 DOI: 10.1016/s0140-6736(14)60421-9] [Citation(s) in RCA: 997] [Impact Index Per Article: 99.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Patients with radioactive iodine ((131)I)-refractory locally advanced or metastatic differentiated thyroid cancer have a poor prognosis because of the absence of effective treatment options. In this study, we assessed the efficacy and safety of orally administered sorafenib in the treatment of patients with this type of cancer. METHODS In this multicentre, randomised, double-blind, placebo-controlled, phase 3 trial (DECISION), we investigated sorafenib (400 mg orally twice daily) in patients with radioactive iodine-refractory locally advanced or metastatic differentiated thyroid cancer that had progressed within the past 14 months. Adult patients (≥18 years of age) with this type of cancer were enrolled from 77 centres in 18 countries. To be eligible for inclusion, participants had to have at least one measurable lesion by CT or MRI according to Response Evaluation Criteria In Solid Tumors (RECIST); Eastern Cooperative Oncology Group performance status 0-2; adequate bone marrow, liver, and renal function; and serum thyroid-stimulating hormone concentration lower than 0·5 mIU/L. An interactive voice response system was used to randomly allocate participants in a 1:1 ratio to either sorafenib or matching placebo. Patients, investigators, and the study sponsor were masked to treatment assignment. The primary endpoint was progression-free survival, assessed every 8 weeks by central independent review. Analysis was by intention to treat. Patients in the placebo group could cross over to open-label sorafenib upon disease progression. Archival tumour tissue was examined for BRAF and RAS mutations, and serum thyroglobulin was measured at baseline and at each visit. This study is registered with ClinicalTrials.gov, number NCT00984282, and with the EU Clinical Trials Register, number EudraCT 2009-012007-25. FINDINGS Patients were randomly allocated on a 1:1 basis to sorafenib or placebo. The intention-to-treat population comprised 417 patients (207 in the sorafenib group and 210 in the placebo group) and the safety population was 416 patients (207 in the sorafenib group and 209 in the placebo group). Median progression-free survival was significantly longer in the sorafenib group (10·8 months) than in the placebo group (5·8 months; hazard ratio [HR] 0·59, 95% CI 0·45-0·76; p<0·0001). Progression-free survival improved in all prespecified clinical and genetic biomarker subgroups, irrespective of mutation status. Adverse events occurred in 204 of 207 (98·6%) patients receiving sorafenib during the double-blind period and in 183 of 209 (87·6%) patients receiving placebo. Most adverse events were grade 1 or 2. The most frequent treatment-emergent adverse events in the sorafenib group were hand-foot skin reaction (76·3%), diarrhoea (68·6%), alopecia (67·1%), and rash or desquamation (50·2%). INTERPRETATION Sorafenib significantly improved progression-free survival compared with placebo in patients with progressive radioactive iodine-refractory differentiated thyroid cancer. Adverse events were consistent with the known safety profile of sorafenib. These results suggest that sorafenib is a new treatment option for patients with progressive radioactive iodine-refractory differentiated thyroid cancer. FUNDING Bayer HealthCare Pharmaceuticals and Onyx Pharmaceuticals (an Amgen subsidiary).
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Affiliation(s)
- Marcia S Brose
- Department of Otorhinolaryngology: Head and Neck Surgery, and Abramson Cancer Center of the University of Pennsylvania, Philadelphia, PA, USA.
| | | | - Barbara Jarzab
- Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Gliwice, Poland
| | - Rossella Elisei
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Salvatore Siena
- Niguarda Cancer Center, Ospedale Niguarda Ca' Granda, Milan, Italy
| | - Lars Bastholt
- Department of Oncology, Odense University Hospital, Odense C, Denmark
| | | | - Furio Pacini
- Unit of Endocrinology, University of Siena, Siena, Italy
| | - Ralf Paschke
- Department for Endocrinology and Nephrology, Leipzig University, Leipzig, Germany
| | - Young Kee Shong
- Division of Endocrinology, Asan Medical Center, Seoul, Korea
| | - Steven I Sherman
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - John Chung
- Bayer HealthCare Pharmaceuticals, Whippany, NJ, USA
| | | | - Carol Peña
- Bayer HealthCare Pharmaceuticals, Whippany, NJ, USA
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Irune E, Dwivedi RC, Nutting CM, Harrington KJ. Treatment-related dysgeusia in head and neck cancer patients. Cancer Treat Rev 2014; 40:1106-17. [PMID: 25064135 DOI: 10.1016/j.ctrv.2014.06.011] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Accepted: 06/26/2014] [Indexed: 10/25/2022]
Abstract
Head and neck cancer patients treated with radiotherapy and/or chemotherapy agents may develop altered taste acuity. This, together with radiation induced xerostomia and dysphagia, is a major contributory factor to the anorexia and concomitant morbidity often seen in this group of patients. This paper examines the existing literature in order to assess the prevalence of clinician and patient-reported dysgeusia in HNC patients undergoing oncological treatment. We also describe the temporal manifestations of the same and its reported impact on QOL.
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Affiliation(s)
- Ekpemi Irune
- Head & Neck Research Unit, Royal Marsden Hospital, 3rd Floor, Mulberry House, London SW3 6JJ, UK.
| | - Raghav C Dwivedi
- Head & Neck Research Unit, Royal Marsden Hospital, 3rd Floor, Mulberry House, London SW3 6JJ, UK.
| | - Christopher M Nutting
- Head & Neck Research Unit, Royal Marsden Hospital, 3rd Floor, Mulberry House, London SW3 6JJ, UK; Institute of Cancer Research, Chester Beatty Laboratories, 237 Fulham Road, London SW3 6JB, UK.
| | - Kevin J Harrington
- Head & Neck Research Unit, Royal Marsden Hospital, 3rd Floor, Mulberry House, London SW3 6JJ, UK; Institute of Cancer Research, Chester Beatty Laboratories, 237 Fulham Road, London SW3 6JB, UK.
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Senior R, Gujral DM, Chahal NS, Harrington KJ, Nutting CM, Shah B. 143 Carotid Intraplaque Neovascularization is Increased in Patients with Prior Ipsilateral Neck Irradiation - A Contrast Enhanced Ultrasound Study. Heart 2014. [DOI: 10.1136/heartjnl-2014-306118.143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Aitken KL, Tait DM, Nutting CM, Khabra K, Hawkins MA. Risk-adapted strategy partial liver irradiation for the treatment of large volume metastatic liver disease. Acta Oncol 2014; 53:702-6. [PMID: 24313391 DOI: 10.3109/0284186x.2013.862595] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Katharine L Aitken
- Department of Radiotherapy, Royal Marsden NHS Foundation Trust , London , UK
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Rogers SJ, Harrington KJ, Eccles SA, Nutting CM. Combination epidermal growth factor receptor inhibition and radical radiotherapy for NSCLC. Expert Rev Anticancer Ther 2014; 4:569-83. [PMID: 15270661 DOI: 10.1586/14737140.4.4.569] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Non-small cell lung cancer (NSCLC) remains the most common cause of cancer-related death in the developed world. Despite advances in therapy with conventional modalities, over 85% of patients will die from their disease within 5 years of diagnosis. For patients with inoperable lung cancer, the addition of chemotherapy to radical radiotherapy yields a small but significant 10% survival benefit at 3 years. However, the systemic toxicity of chemotherapy is common and may be severe. Over the past 20 years, dramatic improvements in our understanding of the molecular etiology of cancer have enabled the development of novel targeted therapies. Overexpression of the epidermal growth factor receptor (EGFR) in lung cancer correlates with an aggressive disease course and poor tumor response to radiotherapy. Strategies to inhibit this molecular switch have become a focus for drug development. Preclinical efficacy has been repeatedly demonstrated with anti-EGFR monoclonal antibodies and small molecule tyrosine kinase inhibitors, and responses have been documented in the clinic with acceptable toxicity. Phase III trials combining EGFR tyrosine kinase inhibitors with radical chemoradiation are recruiting at present. This review addresses the current challenges of discovering how best to use these new anticancer therapies, with particular emphasis on the enhancement of existing therapeutic strategies such as radical radiotherapy, factors relating to patient selection and prediction of clinical response.
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Affiliation(s)
- Susanne J Rogers
- McElwain Laboratories, Tumour Biology and Metastasis Group, Cancer Therapeutics, Institute of Cancer Research, Sutton, Surrey, UK.
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45
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Miah AB, Gulliford SL, Clark CH, Bhide SA, Zaidi SH, Newbold KL, Harrington KJ, Nutting CM. Dose-response analysis of parotid gland function: what is the best measure of xerostomia? Radiother Oncol 2013; 106:341-5. [PMID: 23566529 DOI: 10.1016/j.radonc.2013.03.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Revised: 02/12/2013] [Accepted: 03/06/2013] [Indexed: 10/27/2022]
Abstract
PURPOSE To describe the dose-response relationships for the different measures of salivary gland recovery following radical radiotherapy for locally advanced head and neck squamous cell cancers (LA-HNSCC). METHODS AND MATERIALS Dosimetric analysis of data from the PARSPORT trial, a Phase III study of conventional RT (RT) and intensity modulated radiotherapy (IMRT) for LA-HNSCC was undertaken to determine the relationship between parotid gland mean dose and toxicity endpoints: high-grade subjective and objective xerostomia and xerostomia-related quality of life scores. LKB-NTCP parameters (TD50, m and n) were generated and tolerance doses (D50) reported using non-linear logistic regression analysis. RESULTS Data were available on 63 patients from the PARSPORT trial. Parotid saliva flow rate provided the strongest association between mean dose and recovery, D50=23.4 Gy (20.6-26.2) and k=3.2 (1.9-4.5), R(2)=0.85. Corresponding LKB parameters were TD50=26.3 Gy (95% CI: 24.0-30.1), m=0.25 (0.18-1.0 and n=1). LENTSOMA subjective xerostomia also demonstrated a strong association D50=33.3 Gy (26.7-39.8), k=2.8 (91.4-4.4), R(2)=0.77). CONCLUSION We recommend using the LENT SOMA subjective xerostomia score to predict recovery of salivation due to its strong association with dosimetry and ease of recording.
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Affiliation(s)
- Aisha B Miah
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
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46
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Miah AB, Gulliford SL, Bhide SA, Zaidi SH, Newbold KL, Harrington KJ, Nutting CM. The effect of concomitant chemotherapy on parotid gland function following head and neck IMRT. Radiother Oncol 2013; 106:346-51. [PMID: 23540553 DOI: 10.1016/j.radonc.2013.03.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2012] [Revised: 02/17/2013] [Accepted: 03/04/2013] [Indexed: 11/30/2022]
Abstract
PURPOSE To determine whether concomitant chemotherapy increases the incidence of high grade xerostomia following parotid-sparing intensity-modulated radiotherapy (IMRT) in patients with locally advanced head and neck squamous cell cancer. MATERIALS AND METHODS The incidence of high grade (≥G2) acute (CTCAEv3.0) and late (LENTSOMA and RTOG) xerostomia was compared between patients treated with either IMRT or concomitant chemo-IMRT (c-IMRT) in 2 prospective studies. Parotid gland mean tolerance doses (D₅₀) were reported using non-linear logistic regression analysis. RESULTS Thirty-six patients received IMRT alone and 60 patients received c-IMRT. Patients received 65 Gy in 30 daily fractions to the primary site and involved nodal groups and 54 Gy in 30 fractions to elective nodal groups, mean doses to the parotid glands were comparable. Concomitant cisplatin 100mg/m(2) was administered on days 1 and 29 of IMRT. The incidence of ≥G2 subjective xerostomia was similar in both groups; acute-64.7% (IMRT) versus 60.3% (c-IMRT), p=0.83; late-43% (IMRT) versus 34% (c-IMRT), p=0.51. Recovery of parotid salivary flow at 1 year was higher with IMRT (64% vs 50%), but not statistically significant (p=0.15). D₅₀ for absence of parotid saliva flow at 1 year was 23.2 Gy (95% CI: 17.7-28.7) for IMRT and 21.1 Gy (11.8-30.3) for c-IMRT. CONCLUSION Concomitant c-IMRT does not increase the incidence of acute or late xerostomia relative to IMRT alone.
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Affiliation(s)
- Aisha B Miah
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, Surrey, UK
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47
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Wilkins AC, Rosenfelder N, Schick U, Gupta S, Thway K, Nutting CM, Harrington KJ, Newbold K, Bhide SA. Equivalence of cisplatin and carboplatin-based chemoradiation for locally advanced squamous cell carcinoma of the head and neck: a matched-pair analysis. Oral Oncol 2013; 49:615-9. [PMID: 23485743 DOI: 10.1016/j.oraloncology.2013.02.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Accepted: 02/07/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Carboplatin can be substituted for cisplatin in concomitant chemoradiation (CRT) for locally advanced squamous cell carcinoma of the head and neck (LASCCHN) when the latter is contraindicated. This matched-pair study aimed to compare the efficacy and acute toxicity of carboplatin and cisplatin. METHODS Patients treated with 2 cycles of concomitant carboplatin-based CRT were matched to patients treated with 2 cycles of cisplatin. Matching criteria included age, tumour site, stage, smoking status and use of induction chemotherapy. Radiation was delivered using conformal techniques. Data on weekly acute toxicity throughout CRT was compared using the chi-squared test for proportions. Kaplan Meier statistics described time to local relapse, distant relapse and overall survival, the log-rank test was used to compare 3-year survival outcomes. RESULTS Sixty-five patients who received carboplatin were matched to 65 who received cisplatin. Significant differences in toxicity included increased emesis with cisplatin and more anaemia and thrombocytopenia with carboplatin. There was no significant difference in 3-year locoregional control (87% vs. 79%, p=0.54), freedom from distant metastases (88% vs. 85%, p=0.79) and overall survival (59% vs. 68%, p=0.24) between the carboplatin and cisplatin cohorts, respectively. CONCLUSIONS When cisplatin is contraindicated, carboplatin-based CRT yields equivalent treatment outcomes in patients with LASCCHN.
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Affiliation(s)
- A C Wilkins
- Head and Neck Unit, Royal Marsden Hospital, London and Surrey, United Kingdom
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48
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Popat S, Wotherspoon A, Nutting CM, Gonzalez D, Nicholson AG, O'Brien M. Transformation to "high grade" neuroendocrine carcinoma as an acquired drug resistance mechanism in EGFR-mutant lung adenocarcinoma. Lung Cancer 2013; 80:1-4. [PMID: 23312887 DOI: 10.1016/j.lungcan.2012.12.019] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Revised: 12/13/2012] [Accepted: 12/19/2012] [Indexed: 11/30/2022]
Abstract
Several different acquired resistance mechanisms of EGFR mutant lung adenocarcinoma to EGFR-tyrosine kinase inhibitor (TKI) therapy have been described, most recently transformation to small cell lung carcinoma (SCLC). We describe the case of a 46-year-old female with relapsed EGFR exon 19 deletion lung adenocarcinoma treated with erlotinib, and on resistance, cisplatin-pemetrexed. Liver rebiopsy identified an afatinib-resistant combined SCLC and non-small cell carcinoma with neuroendocrine morphology, retaining the EGFR exon 19 deletion. This case highlights acquired EGFR-TKI resistance through transformation to the high-grade neuroendocrine carcinoma spectrum and that that such transformation may not be evident at time of progression on TKI therapy.
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Affiliation(s)
- S Popat
- Royal Marsden Hospital NHS Foundation Trust, London, and Surrey, UK.
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49
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Tree AC, Khoo VS, Eeles RA, Ahmed M, Dearnaley DP, Hawkins MA, Huddart RA, Nutting CM, Ostler PJ, van As NJ. Stereotactic body radiotherapy for oligometastases. Lancet Oncol 2013; 14:e28-37. [PMID: 23276369 DOI: 10.1016/s1470-2045(12)70510-7] [Citation(s) in RCA: 356] [Impact Index Per Article: 32.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The management of metastatic solid tumours has historically focused on systemic treatment given with palliative intent. However, radical surgical treatment of oligometastases is now common practice in some settings. The development of stereotactic body radiotherapy (SBRT), building on improvements in delivery achieved by intensity-modulated and image-guided radiotherapy, now allows delivery of ablative doses of radiation to extracranial sites. Many non-randomised studies have shown that SBRT for oligometastases is safe and effective, with local control rates of about 80%. Importantly, these studies also suggest that the natural history of the disease is changing, with 2-5 year progression-free survival of about 20%. Although complete cure might be possible in a few patients with oligometastases, the aim of SBRT in this setting is to achieve local control and delay progression, and thereby also postpone the need for further treatment. We review published work showing that SBRT offers durable local control and the potential for progression-free survival in non-liver, non-lung oligometastatic disease at a range of sites. However, to test whether SBRT really does improve progression-free survival, randomised trials will be essential.
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Powell C, Schmidt M, Borri M, Koh DM, Partridge M, Riddell A, Cook G, Bhide SA, Nutting CM, Harrington KJ, Newbold KL. Changes in functional imaging parameters following induction chemotherapy have important implications for individualised patient-based treatment regimens for advanced head and neck cancer. Radiother Oncol 2013; 106:112-7. [PMID: 23089306 DOI: 10.1016/j.radonc.2012.09.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2012] [Revised: 07/09/2012] [Accepted: 09/06/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND When induction chemotherapy (IC) is used prior to chemoradiotherapy (CRT) in head and neck cancer (HNC), functional imaging (FI) may inform adaptation of treatment plans with the aim of optimising outcomes. Understanding the impact of IC on FI parameters is, therefore, essential. PURPOSE To prospectively evaluate the feasibility of acquiring serial FI ((18)F-FDG-PET, diffusion-weighted (DW) and dynamic contrast-enhanced (DCE) MRI) and its role in defining individualised treatment regimens following IC in HNC. METHODS AND MATERIALS Ten patients with stage III and IV HNC underwent conventional (CT and MRI) and functional (DW, DCE-MRI and (18)F-FDG-PET/CT) imaging at baseline and following two cycles of IC prior to definitive CRT. RESULTS One patient withdrew due to claustrophobia. Seven out of nine patients had a complete metabolic response to IC on (18)F-FDG-PET imaging. DCE-MRI showed a significant fall in transfer constant (K(trans)) (0.209 vs 0.129 min(-1)P<0.01) and integrated area under gadolinium curve at 60s (IAUGC6O) (18.4 vs 11.9 mmol/min, P<0.01) and DW-MRI a rise in ADC (0.89 vs 1.06 × 10(-3) mm(2)/s, P<0.01) following IC. CONCLUSIONS Acquiring FI sequences is feasible in HNC. There are marked changes in FI parameters following IC which may guide adaptation of individualised treatment regimens.
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Affiliation(s)
- Ceri Powell
- The Royal Marsden NHS Trust, Surrey, United Kingdom
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